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Home My WebLink About1490A (8)WORKERS' TION DEC I APPLICATION FOR PERMIT that have a certificate cafe of consent I hereby affirm that I have a certificate of consent to self NAME insure, ore certificate of(Sec.Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C. 76A364C HEATING - VENTILATING - AIR CONDITIONINGS a CE -SIB (REV. 10/81) - - Policy No. � -Company . COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDINGi 1 , Q ADDRESS I� tion department. (PRINT OR TYPE ONLY) 1011�)q Date Applicant fif-� LOCALITY L C. CERTIFICATE OF EXEMPTION FROM WORKERS' N0. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST COMPENSATION INSURANCE CROSS ST. (This soctlon need not be completed If the work involved by ABSORPTION UNIT, BTU�� DlstRltt No. PROCESSED BY the permit Is for one hundred dollars (fl Do) or lass.) I certify that In the performance of the work for Ich Jfii 'i_ I �Y O -v AIR HANDLING UNIT, CFM permit is issued, 1 shall not employ any person in ^ ! so Os to b CO A subject to the Worke —o rppe ti w BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date pplitant / !/ /T COMPRESSOR, BTU_ NOTICET APPLICANT: If, after mokin this Cerffiofire VENTILATION SYSTEM Exemption. you should become sublect to the orkeriof Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU. LICENSED CONTRACTORS DECLARATION FLOOR _ I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: '(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Numbe ✓/ � �Q CoMrac ' /- I am exempt u der Sec. y- Plan check fee 8.8P.C. for this reason Signature OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, or my employees with - wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting - with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and Slate Iowslre (Ing to building construction, and here authorize r res tl6iives of this County to enter - upon �� kSnv en ' IT operly for inspection purposes. Signet re of a ant oiAgenVr Dob PERMIT ISSUING FEE $ TOTAL FEE. PIAN CHECK APPLICANT NAME ADDRESS CITY TEL. NO. OWNER L(A/Iai) fif-� a ADDRESS�A-/p / i CITY W Q��TEL. Q��TEL. NO. N0. TEL. NO. LIC. SEE REVERSE FOR EXPLANATORY LANGUAGE - ROUGH FINAL VALIDATION z149,0A 1(.:...g 1. 5200 •Ae52005 G9,09-58 �7 p' p _" F o n o S F F o'i,� a^ """'`^n3a ° m= - o ° mrc,n�__mo 833 0 °�°° °'w°o °,omc ,-0oN©� 9- 3 Onb 'Q• r' V❑ C i O p_ °, r V-❑ N 305.,^�g°�1a°`o°a�C-�A °c ° owns£... cgO34na� �o.�co°o° m'0000 £� O O a' o° m " D ❑—( N 7 m O r; m y 7 'D a - N ° 0 3 3 0 3 -^' C Z N' 2 O*ZOm❑c34 ° b° a s m- ", o °b 'N S rn rLu°.N7 m m O N 1ol p' p _" F o n o S F F o'i,� a^ """'`^n3a ° m= - o ° mrc,n�__mo 833 0 °�°° °'w°o °,omc ,-0oN©� 9- 3 Onb 'Q• r' V❑ C i O p_ °, r V-❑ N 305.,^�g°�1a°`o°a�C-�A °c ° owns£... cgO34na� �o.�co°o° m'0000 £� O ° (L n ° o �,wnb s� e o f m _ m o,� c ° -" �v^.0 7 m - Np°K o°ro�o°°'- 9° 'O Div 0 o° .1.6,�z2 n°£ o' N m ° F o a� m "o n Q o F g o m.° ° o °b aF 3 °07?cx°5.o Fn m'o3 3o'°°o�m o m o cam°©��.`3ac°Na°off£CD "°a7�o�Oa>>o Z o 0 b n o 7 g S a 7 N y o m `[' a o a " o o .;r c. O.o.'U $ v o Ll C: n ] m b O N, h �' m o ?• ^ to Ory 4o s"< a o_ Iso z. O a' o° m " D ❑—( N 7 m O r; m y 7 'D a - N ° 0 3 3 0 3 -^' C Z N' 2 O*ZOm❑c34 ° b° a s m- ", o °b 'N S rn rLu°.N7 ° (L n ° o �,wnb s� e o f m _ m o,� c ° -" �v^.0 7 m - Np°K o°ro�o°°'- 9° 'O Div 0 o° .1.6,�z2 n°£ o' N m ° F o a� m "o n Q o F g o m.° ° o °b aF 3 °07?cx°5.o Fn m'o3 3o'°°o�m o m o cam°©��.`3ac°Na°off£CD "°a7�o�Oa>>o Z o 0 b n o 7 g S a 7 N y o m `[' a o a " o o .;r c. O.o.'U $ v o Ll C: n ] m b O N, h �' m o ?• ^ to Ory 4o s"< a o_ Iso z.