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WORKERS'COMPENSATION DECLARATION CE -818.(2-80) ° o O FOR o o
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate-of Workers'Compensation Insurance,or G,l( Ga4Q(�Gi_M[ l`�`�9L1�76V`G_l�U(�2 ®(�®DSV®(`�7O(�IG
a certified copy thereof(Sec. 3800, Lab.C.)
Policy No. Company
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AMD SAFETY
E Certified copy is filed with the county building inspection.
department. FOR'APPLBCANTTO (FILL CVT ADDRESS
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY �7
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE s
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the ,work involved ABSORPTION UNIT, BTU CROSS ST: O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PRO else ev U
I certify that in the performance of the work for which this Al HANDLING UNIT,CFM lY
permit is issued, I shall not employ any person in any manner L111
�O �ZrZ.�ls�G �� _ - "`� O
so as to become subject to the W 5rkers' Comp e cation Laws. r BOI LER, BTU!7"t �� ��
q` ` APPROVALS DATE INSPECTOR'S SIGNATU E tJIU
Date�yl/�YApplicant_. p(/i-Y) � �i COMPRESSOR,BTU �� �- N
ROUGH
NOTICE TO APPLICANT: if, after.making this Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions_of the Labor.Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FAU GRAVITY'
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
4 (commencing with Section 7000) of Division 3 of the Busi- WALL
mess and Professions Code, and my license is in full force.and °S
effect. J
License Number Lic.Class ;
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect �or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION
PLAN CHECK APPLt NT
I hereby affirm that I am exempt .from- the Contractor's NAME. z15t1 3, 1:A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS # oo o e o,.8
❑ I, as owner of the property, will do the work and*the +
structure is 'not intended or offered. for sale (Section CITY TEL. NO. Z oro 335-0
7044, Business and Professions Code)_ e Y
OWNER �Q o o,o �J Q 0J
I, as owner of the property, am exclusively contracting _ Q ►^.O_U t h - I '
with licensed contractors to construct the project MAIL ! p� d �-- Q 7.2 3'-8 2
(Section 7044, Business and Professions Code). ADDRESS
p ✓ !�� YI e s
CITY /� TEL.NO. I
CONSTRUCTION LENDING AGENCY �Jl� �L- _ djb_4/ 3 b
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR /
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS I� -
Lender's Address
CITY .TEL.NO.
I certify that I have read this application and state that the_ STATE LIC.
above'infor�-^tion is correct.I agree to comply with all County LICENSE NO. CLASS . . .
ordinance, ,nd State laws regulating Heating, Ventilating and
Air Con ditic ping and hereby authorize representatives'of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to +rtes upon the above-mentioned property for
A, pectio i pi I ose
Signature o:•ermi '.ea Date