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WQRKER'SCOMPENSATate of consent to 200048 DPW 9/89 APPLICATION FOR PERMIT LIMEGREEN
78A364C
I hereby affirm that l.have.a certificate of consent to self insure,
.or a certiffoatb df Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) L
•Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified co Is filed with the coun buildin Ina ection FOR APPLICANT TO FILL IN BUILDING /_ /�—
department. �• 9 p (PRINT OR TYPE ONLY)
ADDRESS (®
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need-not,be completed if the work involved by-the ASSESSOR
MAP BOOK PAGE O// PARCELb
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
Icertify that in the performance of the work for which this permit
is issued, I all not employ any person in any manner so as to BOILER,BTU D
become su --tto the Workers'Com ens 'on Laws. /
COMPRESSOR,BTU - �J
d. APPROVALS DATE INSP R'8 SIGNATURE
Datlel— Applicant VENTILATION SYSTEM
NO T4 APPLICANT: If, after making this Certificate of ROUGH
Exem
Atlon',lyou should become subject to the Workers'Compensation EVAPORATIVE COOLER `
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE:
FLOOR FAU G Ll �(LICENSED CONTRACTORS DECLARATION
O VALIDA ION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER, WALL
Professions Code,and m Iicen a is in ful force and
/effect.
0
License Number LID.Class, s _
�V , C
Contracto ' Date l C
❑ I am a mpt under sec. Plan check fee a
BAP.C.for this reason PERMIT ISSUING FEE C
Date: TOTAL FEE n
Signature U,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 2
I herebyaffirm that I am exempt from the Contractor's License Law NAME polo.for the following reason (Section 7031.5, Business and Professions -
Code): ADDRESS °
I, as owner of the property, or my employees with wages 3303
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, /� — 1 ITEMS
Business and Professions Code). OWNER 7� /1
❑ I, as owner of'the property, am exclusively contracting +p�
with licensed contractors to constructthe project (Sec- ADDRESS ?
tion 7044,Business and Professions Code). y
CONSTRUCTION LENDING AGENCY C / �EL.N . �'' CHANGE
I hereby affirm that there is a construction lending agency for CONTRACTOR. ,
the performance of the work for which this permit Is Issued
(Sec.3097,CIv.C.). r�r� {y �7/ /�y .
ADDRESS i[�) QQVLI-UOQ1 57f 1/7� .
Lender's Name i � .{i
1
CITY TEL. r 1631 1 AI{17 p 0-d
' 4
Lender's Address
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hole authorize
representa'Ves of this County to enter upon the �.ETE oned
pAerorms ection purposes. SEE REVERSE FO/EXPLANATORY LANGUAGE
IAPPLICANT OR AGENT