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WORKERS'COMPENSATION DECLARATION. APPLICATION FOR- PERMIT
I hereby affirm that I hale a certificate of Consent to self � -
Insure, or a certificate of Workers' Compermatlon Insurance, HEATfN.G - VENTILATING-- AIR CONDITIONING
CE-81
or a certlfled copy thereof (Sec. 3800, Lab. C.) C
�-els(REV. loisl)
Policy
ert Company
Certified! copy Is hereby furnished.. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING �/
tlQn department. 7r
(PRINT OR TYPE ONLY) ADDRESS 17
Date Applicant LOCALITY �_
NO. TYPE QF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST (I'llinAPI 14
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed If+he work Involved by ABSORPTION UNfr, BTU py-q�L7 NO. ruoc ssm BY
the permit Is for one hundred dollars ($100)or Inas.)
I certify that In the performance of the work for which this AIR HANDLING UNIT,CFM �C.J
permit Is Issued, I shall not employ anyrson In any manner
to as to become subject to the Workers Compensation Laws-. BOILER, BTU APrvnnovUs DATE rNWECTOWS SrNATURE
Date/ J�_ ATpllcanT COMPRESSOR, BTU ROUGH S2
NOTICE TO APPLICANT: If, after malliAg 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 VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked. RJRNACE:• FAU_d.-- GRAVI
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am Ilcerm!d under provisions of Chapter HEATER: SUSPENDED UNIT
'(commencing.with Section 7000)'of Division 3 of the Business WALL
and Profeesions Code,and my license Is In.full force and effoct. d
O
License Number LIc. Close ► U
OC
Contractor Date O
I am exempt under Sec.
Plan check fee
B.BP.C. for this reason
Date: �
PERMIT ISSUING FEE $
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
I hereby affirm that I am exempt from the Contractbr's License
Law for the following reason (Section 7031.5, Business and NAME lme
Prof Ions Code): Q �j Q - 901.7.A
as owner of the property, or my employees wltf 4DDRE55 / O e J
/ wages as theirsole compensation,will do the work and 0 0 0 0 .0 8
NO
the structure Is not Intended or offered for sale(Sectlon CITY TEL ' 6172S 3
7044, Business and Professions Code). °,- 3 (150
OWNER
❑ I, as owner of the property, am exclusively contracting ,o 1 o o j a 5 0
with Ilcensed contractors to construct the project (Sec- MAILRESS 1C
S
tion 7044, Buslness and Professions Code
� 0,1,.1 2-83
CONSTRUCTION LENDING AGENCY CITY &q?n r TEL NO.
I hereby affirm that there Is a construction lending agencyfor ,
the performance of the work for which thls'.permLt Is Issued CONTRACTOR j�5VW(V JL
(Sec. 3097, Civ. C.).
ADDRESS
Lenders Name
CITY TEL NO.
Lender's Address
I certify that I have read this application and state that the STA LIC
L NO. CLASS
above Infornwtlon Is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
n the abovo- entl ro "rty for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
42
Slgr Appllconi or Agent Date