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DECLARATI
2MO
WORKER'S I veMa certificate
of consent to 76A346DPW9le9 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have`a certificate of consent to self insure,
76A304C
or a certificate of'Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy Is hereby furnished.
ILDING
❑ Certified copy is filed with the county building inspection FOR APRIPILIOCA NT TTYPE OOLFILL IN ADDRESS y 8 v'����01�/7f�
4W
department.
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAR
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work involved by the ASSESSOR
MAP BOOK D7L PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I c rtify that in the performance of the work for which this permit
Issued, I shall not employ any person in any manner so as to BOILER,BTU O
become subject to the Workers'Compensation Laws. (/0-
�J COMPRESSOR,BTU Z �o
APPROVALS DATE INSPECTOR'S SIGNATURE
Date 5 7 1 Applicant,/L�Gr � VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such I FINAL
provisions or this permit shall be deemed revoked. i FURNACE: FAU GRAVITY 2 os- VALIDATION
LICENSED CONTRACTORS DECLARATION i FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license Is In full force and effect.
60 (AA
2
License Number Lic.Class
EL
Contractor Date C
❑ Plan check fee C
I am exempt under Sec. a
BAP.C.for this reason PERMIT ISSUING FEE$ 2(Q _0 F
`
Date: TOTAL FEE 02 Uo LL
d
Signature _ U,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License Law NAM , I A
for the following reason(Section 7031.5, Business and Professions
Code): ADD S 71:1.7.
EJ ]. a 1:
I, as owner of the property, or my employees with wages _
as their sole compensation, will do the work and the CITY TEL.NO. = i 1=NG
structure is not Intended or offered for sale(Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL d"IEVs 'AI,'.+.aC
_3
with licensed contractors to construct the project (Sec- ADDRESS tt��h
tion 7044, Business and Professions Code). CITY TEL.NO. �ClttN;SL 4111
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agCONTRACTOR ency for
the performance of the work for which this permit s issued �
(Sec.3097,civ.C.). =i?130-1_1:G 1 2 j/14.
r
Lender's Name ADDRESS 3360 1 AM 11:i
CITY TEL.NO.
Lender's Address STATE LIC.
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
/rnd State laws relating to building construction,and hereby authorize
epresentatives of this County to enter upon the above-mentioned
props y for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DA E