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WORKY;ItS'CUMY]i:NSATION DECLARATION 76A364C
CE -818 (2-80) A\ I� I>- I� CAT 0 OO U CI FOR If—E R M PT
I hereby affirm that I have a' certificate of connnt to self „
insure,or a certificate of Workers'.Compensation Insurance,or Fp[ (qTI( -y( � I�ATIW�si-AV4@CONDITIONING
a certified copy thereof(Sec. 3800, Lab. C.)
PolicyCompaur COUNTY OF LOS ANGELES � BUILDING AND SAFETY
Certified copy is hereby furnished. � .
Certified copy is filed with the county building inspection FOR APPLICANT TO'FI LL IN BUILDING
department. g� _/ Digirve
,Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY t
CERTIFICATE OF EXEMPTION PROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEErnP.Ze
COMPENSATION INSURANCE NEAREST(,/,`
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. d
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO.. PROCESSE Y ^ 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner J•�G
so as to become subject 16 the Workers' Compensation Laws. BOILER,'BTU0
- APPROVALS DATE INSPECTOR'S SIGNATURE V
Date Applicant COMPRESSOR,BTUJ W
ROUGH D Zc�=(�' ✓ 0-
NOTICE
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL V. Z
Exemption,. you should become subject to the Workers'
Compensation provisions ofthe 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: N D E D UNIT•
9 (commencing with Section 7000) of Division 3 of the Busi-
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 Pian Check fee 25%of above.
acting in my professignal capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $ D
Lie,or Reg.No. Date TOTAL FEE j:U
HOME OWNER-BUILDER DECLARATION PLAN CHECK A,
LICANT
I hereby affirm that I am exempt from-'fhe Contractor's NAME _
License Law for the following reason {Section 7031.5, Busi-
ness and Professions Code).: ADDRESS
QI, as owner of the property, will-do the work and the
structure'is not intended or offered for sale (Section. CITY TEL. ND. �*7
7044, Business and Professions Code). OWNER �,`3t' a,1 A
DI, as owner of the property, am exclusively contracting IL_� �_��__/�✓�
with licensed contractors to construct the projectAIL F
# o 0 0 0'0 8
(Section 7044,Business and Professioes Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY
r �`e TEL NO.2�p qQ3 2 °i° 2 5 O
I hereby affirm that there is a construction lending agency !—P)'!'l ° j =
for the performance of the work for which this permit is
CONTRACTOR
y °IO 1° 2 3`5 O,U
issued (Sec. 3097,Civ.C.)- e ;
Lender's Name ADDRESS I� 0 4,2j6;:-8'2
.Lender's Address CITY / TEL.NO.
1 certify that 1-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
County to enter upon .the above-mentioned property for
ins tion purpr e
Sign.ure or "Inittee Date