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WORKERS COMPENSATION DEC-tiRATIC'N CEA 318'(280) A P P IL C AT I ON FOR P E R Vv%If T
I hereby affirm that I have a certificate of consent to self
insure c,' a certij.cate of Workers Compensation In?urance or HEATING VENTILATING-Alps CONDITIONING
a certified -opy thereof(Sec 3800 Lab C) "fl
PPolicy No Company COUNTY OF LOS ANGELF{S �(;P BUILDING AND SAFETY
Certified copy is hereby furnished �/
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING ���
department 1�
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY -
re_ �
ChRTIFICATE OL`EXEMPTIdN FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION '� —
INSURANCE NEAREST
CROSS ST
(This section need not be completed if the work involved ABSORPTION UNIT BTU—
by
TU by the permit is for one hundred dollars ($f00) or less) DISTRICT NO PROc BY O
I certify that in thi, performance of the work for which this AIR HANDLING UNIT CFM V vU
permit is issued I shall nol employ any person in any manner
so as to become subject to the Workers Compensation Laws BOILER BTU
APPROVALS DATE INSPECTOR S SIGNATU U
Date Applicant COMPRESSOR BTU ROUGH ���" W
NOTICE. TO APPLICANT If after making this Certificate of VENTILATION SYSTEM N
Exemption you should become subject to the Workers FINAL �3� ar Z
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 FAUG VI Y
LICENSED CONTRACTORS DECLARATION FLOGR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT e
9 (commencing with Section 7000) of Division 3 of the Bust WALL
ness and Professions Code and my license is in full force and
effect
License Number Lie Class
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $
Lie or Reg No Date TOTAL FEE h
HOME OWNER BUILDFR DECLARATION PLAN CHECK APPLICANT (1 O rJ GOR i
I hereby affirm that I am exempt from the Contractors NAME O��
License Law for the following reason (Section 7031 5 Bust
N ness and Professions Code) _ - ADDRESS N do fe
I as owner of the property will do the work and the o�f x +
structure is not intended or offered for sale (Section CITY rl / TEL NO �G ! ��5 2,7 3 4 A
7044 Business and Professions Code) OWNER^ -i# o o o+o o $
ElI as owner of the property dm exclusively contracting Sa 1'Yl e 1
with licensed contractors to construct the project MAIL 2 oLo 2 3 5 O
(Section 7044 Business and Professions Code) ADDRESS +
s i Z
CONSTRUCTION LENDING AGENCY CITY TEL NO a to 5
;0 2 3,5 O
I hereby affirm that there is a Lonstruction lending agency F 0 1 25-82
'
for the performance of the work for which this permit is CONTRACTOR
issued(Sec 3097 Civ C) i
Lender s Name ADDRESS
Lender s Address CITY e TE r
I certify that I have read this application and state that the STATE 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 FOR EXPLANATORY LANGUAGE. -
Count�k�sz
tent-r upon the above mentioned property for
/�, /—.?5-��2
Signature of Permittee ])ate
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