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1VURKRS'COMPENSATION DEC.ARRTION CE'-88 (2-80) APPLICATION
POLICATION rp PERMIT GRMIT
7 hereby affirm than I have a' certificate of consent t6 self �I'L.IifI
11 arc, c` ��itYieatz Ot iVOPkers Compensation Insurance, HEATING-VENTILATING-AIR -CONDITIONING '
a certified copy thereof(Sec. 3500, Lab C.)
Policy No- Company '
❑ Certified copy es hereby furnished:' COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copyis filed with the county building inspection BUILDING —�/D/f
derartment. FOR APPLICANT TO FILL IN ADDRESS Vx 7
Date Applicant (PRINT OR TYPE ONLY) -
LOCALITY , 1 C • _
CERTIPICA7E OT EXEAIPTION rR'OM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT .FEE /J
COMP?NATION INSURANCE NEARESTA
y�, }
CROSS ST.
('this section need not be completed if the Work Involved - - ABSORPTION UNIT, BTU rL. CL
by the portrait is for one hundred dollars (S100) or Iasi.) - DISTRICT ND" PROCESSED By O
I certify thrf In the performance of the work for which this AIR HANDLING UNIT,CFM Lr` /lam
permit is issued, t shall not employ any person in any manner
so as to become soh^.t to the Workers`'/.m/�.hsaC rr Law . BOILER, BTU O
APPROVALS DATE INSVETC fS 51GNGTURE 16-
cant
cant /r(J�///C//•+f [�/IVCOMPRESSOR, BTU ROUGH I_ I N
NOTICE TO .1 PPLIL'ANT: jf, after making this Certificate of VENTILATION SYSTEMj '
Exemption, YOU.Should become subject-to the Workers' FINAL _ yy _ _ Z
Compensation prOvisforrs of the Labor Code, you must forth.
with comply with Such provisions of this permit shall be EVAPORATIVE COOLER ' VALIDATION
deemed revoked. FURNACE: FAU—GRAVITY—
LICENSED CONTRACTORS DECLARATION - FLOOR: BTU
—
I hereby affirm that i am licensed under provisions of Chapter / HEATER: SUSPENDED UNIT jI
9 (commencing with Section 7000) of Division 3 o the Busi- WALL
ness and Professions Code, and my licenseisin full force P Id,' - � , 7 9 A
effect.
License Numbe-� U .Aass_I�_._
Contr
❑ I am exampt from the licensing requirements as I am.a - °'! •21.0 O9
licensed architect or a reristered professional engineer Plan check fee 25%of above.
acting in my professional'capacity, (Section 7051. Bps- 329-85
iness and Professions Cade): PERMIT ISSUING FEE $ Q o'
Lie,or Reg.No. Date TOTAL FEE" 1/1106
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that. I ant exempt from- the Contractor's ' NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code)- ADDRESS
❑ 1, as owner of the property, will do the work and the
structuro is not intended or offered for Sale (Section CITY TEL..,NO. -
7044} Buuiness and Professions Code).
OWNER '
l; as owner of the property, am exclusively contracting
.4ith licensed contractorsto construct the project MAIL
(Section 7044, Business and Professions Code). I ADDRESS
fflNSTR UCTION.L EhfDING AGENCY ' CITY TEL.NO. .
I hereby affirm that Them is a construction lending agency CONTRACTOR
'
for,the performance of the Mork for which this permit is
issued(See. 3097,Civ.C.). ,
Lender's Name' ADDRESS '
Lender's Address t CITY - TEL. NO.
I certify that I have read this application and State that the STATE - LIC. "
above information is cOrreet. I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating heating, Ventilating and
Air Coildti 'ig,and hereby authorize repr^sentatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County) - - .po- the al- .etner ,ned properly for '
h1SPer
3fiS
SignatufeUf Perm-tee Date _ -