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RKERS'COMPENSATION DECLARATION 76A364C p no no p o (o 0
jI affirm that I have a certificate of co+se;it to elfCE-818,(2-80) QfIUP � CATUOU�J FOR If'lERMM
a certificate of Workers'Compensation Insuranceorcopy theree ec�00,y.ab.C.)�oUUmpan��.
7 t�3copy is hereby furnished. C®����®� ®� �'�����5 BUOLD6NG AND SAFETY
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL ON BUILDING �����` �(✓�
department. J
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST ✓ l J
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. pG - 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY V
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM � Ir�
permit is issued, I shall not employ any person in any manner • q Q
so as to become subject to the Workers' Compensation Laws. BOILER, BTU 1--
APPROVALS
—APPROVALS DATE INSPECTOR'S SIGNATURE U
Date Applicant COMPRESSOR,BTU ROUGH _ y
NOTIP. CE 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 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: S .NDED_ UNIT _
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
mess and Professions Code, and my license is in full force and i
effect. 77��
License Number__ _- _ LClass—
p—
Class �j
Contractor. G�(` LD ate-Y=/��d
I am exempt from the licensing 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). PlERMOT ISSUING PEE $
Lie.or Reg,No. Date ®TAL (��� 2®
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 2.5 4 Q,9 A
I hereby affirm that I am exempt from- the Contractor's #' o o 0 o 0 8
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS �e.I-pj-�v e I,o o 2
ElI, as owner of the property, will do the work and the / 1 lo,0 0 2 Q 5 0'25structure is not intended or offered for sale (Section CITYLe c�/� TEL. NO , ,
7044, Business and Professions Code). OWNER /�
le-
with
1/e 0 .9, 2 0—8 3
'7s(iE•� C P/J�S��
I, as owner of the property, am exclusively contracting
/
with licensed contractors to construct the project MAIL
Section 7044, Business and Professions Code). ADDRESS CJ jj`
Y 1 TEL.NO
CIT
CONSTRUCTION LENDING AGENCY /eynP/e_Gi'�/
I hereby affirm that there is a construction lending agency `
for the performance of the work for which this permit is CONTRACTOR ;—Fa ,�Q✓/�V
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address
CITY I TELL oa _
I certify that I have read this application and state that the STATE ¢.
above information is correct.I agree to comply with all County LICENSE NO. 7-3( 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 a - ,boventioned property for
inspection purrnnIF
Signature Permittee Date