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WORKFRS'COMPENSATION DECLARATION 'f6A364C- APPLICATION
I� p y N R PERMIT p M 4
1 hereby affirm that I have a certificate of consen_to self CE -818 (2-80) P'i Ir t�tC P9 1 1 O 1 tl FO f'C 1�t�YC IVI I 1
insure, or a certificate of Workers'Compensation Insurance.o} HEATING-VENTILATING-AIR CONDITIONING
a Certified copy thereof(i e.. 38000,,LLab.C.)
Policy No.('—)q-36Q5 Lompan yyZTJ.1e
JZLCertined copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed witq.the coo y i mg inspection BUILDING
department. SuPJ �utl "i 1 �• FOR APPLICANT TO FILL IN ADDitE ;S
Date 11-2 -31 Applicant (PRINT OR TYPE ONLY) Y
LOCALITY
TempleCERTIFICATE OF EXE M TION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEARESTf
(This section need not be Completed if the work involved ABSORPTION UNIT, BTU CROSS ST. `,Tp tcfe,, LvC-a+ O
by the permit is for one hundred dollars (SI00) or less.) - –J LJ C DISTRICT NO. PFO �ayESU
�. `/
I certify that in the performance of the work for which This AIR HANDLING UNIT,CFM' St D 7t cc is issued, i shall not employ any person in any manner l�
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE I :SECT OR'SG >TUR. tU
Date - APplican[ COMPRESSOR,BTU ROUGH I ( _ _ y
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 VALIDAT ON
with comply with such provisions or this permit shall be —
deemed revoked - FURNACE: FAU— GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
I herebv•affirm that I am licensed under provisions of Chapter NEATER: SUSPENDED UNIT p L 7
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in,full force and
es
Lieffect.
N3354L �f}�
Lcennse Number Lia Class 1 1 9.4 A
C Iz 7 -3y - q . .;. . . 8
Contractor,)ant Fats —}J�
rr equine 1 • • 2 0 5 0
1 am exempt from tl a licensi 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) PER!!T
ISSUI �E ,�,
/U StD e e - 2Q5001
Lic.or Reg.No. Date OTAL o ✓ O 1 2 0 7'8 4
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT '
I hereby affirm that I am exempt from-the Contractor's NAME -
License Law For the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
0 1, as owner of the property, will do the work and the CITU TEL. NO.
structure is not intended or offered for sale (Section _
7044, Business and Professions Code). I
'^J
OOWNER Net
1, as owner of the property, am exclusively contracting '
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS
UI•
CONSTRUCTION LENDING AGENCY _ I e'"'1 p1l �'�Y CITY TEL. N -Illy? ( 30
I hereby affirm that there is a construction lending agency I (
for the performance of the work for which This permit is CONTRACTOR p _
issued(Sec. 3097.Civ.C.).
Lender's Name ADDRESS 'Z�'Jf l' e-y4 -(N�" Ale
Lender's Address CITVG U �1 TEL. NO. �t,i�� 7�'7S
I certify that 1 have read this application and state that the STATE` 11]] 1� fJL LIC. p
above information is correct.1 agree to comply with all County LICENSE NO. 9. S I CLASS _ tJ
ordinances and State laws regulating Hearing, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE. FOR EXPLANATORY LANGUAGE
County to a ter upon the above-mentioned property for
iZ -2 JO
Z
/Signature o Permittee Date