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•WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
�'*I h y'affirm that I hpve a cerlifLcatq of consent to self
insu4, 'or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C. CE_81 C
�—p.,��� j L CE-818(REV. 10/81)
Policy No. Companyished. 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 BUILDING l
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE (� f7
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PRO ss BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIG TORE
Date Applicant COMPRESSOR, BTUa�/.UUD �! �0 ROUGH �SU
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU f GRAVITY Q�
LICENSED CONTRACTORS DECLARATION FLOOR _BTU__'! D ' d
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDEDUNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code, and my license is in full
ryforc2and effect. AJ 4 43 7�-�
ULicense NumbesMBO Lic. Class G.qo
T2N/� t4 ` 70
Contractor4- DaIM
t—
❑ 1 am exempt under Sec. w
Plan check fee 0-
B.&P.C. for this reason N
PERMIT ISSUING FEE (? U Z
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting OWNER
El 99'
with licensed contractors to construct the project (Sec- MAIL
/D
tion 7044, Business and Professions Code). ADDRESS U)j55 7_X AJ '
CONSTRUCTION LENDING AGENCY CITY`�� ��� e-4,
TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR Iq
(Sec. 3097, Civ. C.). �� )
ADDRESS •S !/" ,/1�,
Lender's Name 1.+ ��/ C�
Lender's Address CITY' /� TEL. NO"2,65.- /�/g
STATE LIC.
I certify that I have read this application and state that the LICENSE NO CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and herebyauthorize re 'esentatives of this County to enter
upon the above-menti ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date