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WORKERS'COMPENSATION DECLARATION ,N CEAE-:8 (2-80) QppL��OQT�ON FOo R p E R(�l Ty affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insur nce,or
a c/�4i4iedyioZpyy hereRff(Sec. 3800 '.ab.C)
Pul'icy No(� __Ompany_ ��
(� Certified copy is hereby furnished. --- — COUNTY OF LOS Aftl('sELES � � ' X116 L®Of�O AND SAFETY`►,' P
1 Certified copy is filed with the^ounty building inspection BUILDING
den tme�r POffi APPLICANT TO FILL 9fi!
Date. � jApplicant �-X , (PRINT OR TYPE ONLY) ADDRESS
i /— LOCALITY , Pf
ERT FICATE OF EXEMPT N FROM WORKE NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST CROSS ST. � J a
(This section need not be completed if the work involved ABSORPTION UNIT, BTU
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED Y V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM f/ it
permit is issued, I shall not employ any person in any manner cem
so as to become subject to the Workers' Compensation Laws. BOILER, BTU ryry , F—
Date Applicant COMPRESSOR, BTU_ G e /o APPROVALS DATE fNSPECTOR'SSIGNATURE 1 W
ROUGH '9�p'" 1 N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM / - Z
Exemption, you should become subject to the Workers' FINAL > oa-mss
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: FAL RA�pITY
LICENSED CONTRACTORS DECLARATION FLOOR:
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDEDUNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number?-73Z9— Lic.Class C
Contracto _ are
ElI arrl'e :mpt from th licensing r,qutrem,.its 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 EEE $
Lic.or Reg.No. Date TOTAL EEE 30 So
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- a2 1 &'9 A
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the #}o oro 0 08
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). 2 -.- 30,50
OWNER
1, as owner of the property, am exclusively contracting lo'o0 3 Q`6 U
with licensed contractors to construct the project MAIL Tr
(Section 7044, Business and Professions Code). ADDRESS�J;n�_ 0624'-83
CONSTRUCTION LENDING AGENCY CITY, L.NOZ &-I•hereby affirm that there is a construction lending agencyCONTRAC Rfor the performance of the work for which this permit is .4- / li
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS/
Lender's Address J 36 lY `
CITY TEL. NO. _ & Ol!
— — /—/
I certify that I 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 nter upon the a,,v:-mentioned property for
iuspe :5n purl,.ses.
_ 5- -
Signature Pero ittee Dat'