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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
4 hereby affifm that I have a certificate of consent to self -
�insurb,,,or-a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
M acertified copy thereof (Sec. 3800, Lab. C. 76A364C
� �UN CE-818(REV. 10/81)
Policy o. ompony
�1(J, Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building i=spec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS /Ycj A
(/ (PRINT OR TYPE ONLY)
Date ~� �" Applicant LOCALITY e
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. L(/WP 2
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PR D
the permit is for one hundred dollars ($100)or less.)
AIR HANDLING UNIT, CFM jj v1
I certify that in the performance of the work for which this (J
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPE TOR'S 51-d TURE
Date Applicant I COMPRESSOR, BTU y G �� -� ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of , VENTILATION SYSTEM FINAL
Exemption, you should become subject to the'Workers' f
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. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter9SUSPENDED UNIT -
(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
-and Professions Code,and my license is in full force and effect. CL
License Number [ U 9 2✓Y Lic. Class C S , 0
Contractor (o�/U/0-y2 Date -/�-�
❑ I am exempt under Sec. LU
Plan check fee CL
B.&P.C. for this reason PERMIT ISSUING FEE
Date:
Signature
TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License pop.Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ .I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. ;25 2 7.9 A
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). # 0 0 o e 0 8
E] 1,
Q •,[.
I, as owner of the property, am exclusively contracting �U 2l 2 's 0 - 51.50
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS U U"'Ir 0 0 0
CONSTRUCTION LENDING AGENCY CITY TEL. NO5 1.S O csi
. ( ! 77
I hereby affirm that There is a construction lending agency for O 8 1 9-86
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). �!7 /I/d /rte 2 C 0/VAPiO�ii
ADDRESS Cf N
Lender's Name Q
-7
CITY �e1W Cy,` TEL. NO. Y �/Y_?b
Lender's Address
STATE LIC.'
I certify that I have read this application and state that the LICENSE NO. Yo J7 3 S CLASS C
above information 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
u7the ove-mentie property for inspection ,C oses. .SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date ,