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WORKERS COMPENSATION DECLAR'TION l 76A364C (� A y� p p (�(�[�
I hereby affirm that I have a certifreaie�'a°
WA- io s if �ICF $18(2 80) A Ir P L4�IC{moi T�®1�I FOR P E R II�U T
insure or a certificate of Workers Corpensation In.urance for HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 Lab C) f
Policy No Company
Certified copy is hereby furnished 1
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the count) building mspectipit FOR APPLICANT TO FILL IN BUILDING
department ADDRESS
J o
Date Applicant (PRINT OR TYPE ONLY)
CI RTIFICATE OF EXEMPTION FROM WORKERS t NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY —
NEAREST
COMPENSATION INSURANCE CROSS ST O}.
(This section need not be completed if the work involved ABSORPTION UNIT BTU O
by the permit is for one hundred dollars ($100) or less) DISTRICT NO ` PRO,C--S D BBy V
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM �^ {{ (�Y`�' cc
permit is issued I shall not employ any person in any manner O
so as to become subject to the Workers Compensation Laws BOILER BTU 1—
APPROVALS DATE INSPEC OSIGNAIIUIRIE
W
Date Applicant COMPRESSOR BTU — tL
ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM Z
Exemption you should become subject to the Workers FINAL
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER L�+— A i N
with comply with such provisions or this permit shall Ibe
deemed revoked i ,�
LICENSED CONTRACTORS DECLARATION " FURNACE FAU GRAVITY-----L
FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi WALL
ness and Professions Code and my license is in full force and
effect
License Number Lic Class "
� 1440A
•
Contractor Date o o e o 8
e
I am exempt from the licensing requirements as I am a l 02(150,.
licensed architect or a registered professional engineer Plan check fee 25%of above
acting in my professional capacity (Section 7051 Bus /� o o e 2 a 55 05
iness and Professions Code) PERMIT ISSUING FEE $ lU D
Lic or Reg No Date TOTAL FEE 1 30-85
HOME OWNER BUILDER DECLARATION IPLAN CHECK APPLICANT
I hereby affirm that I am exempt from the-Contractors NAME
License Law for the following reason (Section 7031 5 Bust -—
ness and Professions Code) ADDRESS �C / �r—T
1 as owner of the property will do the work and the CITY EL NOstructure is not intended or offered for sale (Section _ C�4 7-%-3-7)7044 Business and Professions Code) r�
DOWNER 4
I as owner of the property am exclusively contracting
with licensed contractors to construct the project MAIL t
(Section 7044 Business and Professions Code) ADDRESS ALY
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is tA+
issued (Sec 3097 Civ C)
Lender s Name ADDRESS
Lender s Address
CITY TEL NO
I certify that I have read this application and state that the STATE s LIC
above information is correct I agree to comply with all County LICENSE NO CLASS
ordinances and State laws regulating Heating Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE IOR EXPLANATORY LANGUAGE
County to enter upon the above mentioned property for
ms tion purposes
_ _ _�Q
Signature of Pe�itt Date
T