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'WORKER'S th.t"Ihave a certificate
of consent to 77BBA364C PW 9/89 APPLICATION FOR PERMIT LI E GREEN
I hereby affirm that''I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
Wy therredff((SSec.3800 Lab.C.)
Policy No. �d 2'd;'/0'-W Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND-SAFETY DIV.
Certified copy isherebynumished.
Certi ed cop 's filed with the county bull ing inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS
de rtment. • (PRINT OR TYPE ONLY)
Dat li a LOCALITY ILI
App
17. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CE IFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU i
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you 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: FAU �r
LICENSED CONTRACTORS DECLARATION FLOOR BTU 3 J F VALIDATION
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 my license is in full force and effect.
•I
License Numbe Lic.Class'
°c
L
Plan check fee
I am•exempt un r Sec.
C
B.&P.C.for this reason PERMIT ISSUING FEE r
Date: TOTAL FEE ::L1..U�.�'° _ 5.5'_ 'U
Signature lb f
PLAN CHECK APPLICANT �l,I•_
a -%Z% :.4!c•- U,
OWNER-BUILDER DECLARATION 6
I hereby affirm that I am exempt from the Contractor's License Law NAME 111110.
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
El1. as owner of the property, or my employees With wages rl i;i;yl_ i_yl i'•�� '4sy
as their sole compensation, will do the work and the CITY TEL.NO.
-:t: '4 r_a
structure is not Intended or offered for sale (Section 7044, � A,-•E�i; _ =l•?,,,, j
-Business and Professions Code). OWNS
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for ® I
the performance of the work for which this permit Is issued CONTRACTO
(Sec.3097,Civ.C.).
ADDRES
IL
Lender's Name
CEL. �(r
Lender's Address STATE LIC. U
I certify that I have read this application and state that the above LICENSE NO CLASS 4-- 2 42
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter;uponove- ntioned
property r Au ,_J"
pd§es SEE REVERSE FOR EXPLANATORY LANGUAGE
l z
PPLICA AGENT ATE