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WORKERS'.COMPFNSAT?GN DECLARATION .• CE-818 (2.80) �G�1 ll— If— UC AT�O N FOR PE R MT
I hereby affirm that I have a certiileate of conse:it to self
insure, or a certificate of Workers'Compensction Insurance,or HEATONG_VENTOLATlNO_AIR CONDOTVOI ONG
a certified copy thereof(See.3600,T.ah.
Policy No. Company `
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county bu g ins-^ction BUILDING
d-)artmentp FOR APPLICANT TO FILL IN .�/
(PRINT OR TYPE ONLY) ADDRESS 2
LOCALITY C.,�e
CERTIFICATE OF EXEMPTION FRO' WORKERS' � NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATIOiiT INSURANCE NEAREST
(This section need rot bz cou-19lo,ee ?: the work involved d ABSORPTION UNIT, BTU CROSS ST� G�Gs7 �.� 0
by the pertnct is :O.- OTe Lu7-,C.:e6 C_s275 (; GD) or less.) IDISTRICT NO. / PROCESSE V
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 1r
permit is issued, I shall not employ any person in any manner Q
so as to become subject to the Workers' Compensation Laws. BOILER,BTU r F—
APPROVALS DATE SPECTOR'S SIGNATURE U
�{ �r W
Date Applicant � COMPRESSOR,BTU— 60
NOTICE TO APPLICANT: if, after making thin Certificate of VENTILATION SYSTEM FINAL 2
Exemption, you should become subject to the Workers'
Compensation provisions of 'he Labor Coe e, yqu must forth- j EVAPORATIVE COOLER
with comply with such provisions or this permit shall be n D VALIDATION
deemed revoked. FURNACE: FAU — GRAVITY
LICENSED CONTRACTGRSDECLARA'TION FLOOR BT
I hereby affirm that I am iicensed ender provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing wit;; Section 7000) of Division 3 of the Busi- ii WALL
ness and Professions Code, and my license is in full force and
effect. `� _ J
License Number v�2//�j_ Lie. Class �? a
ContractorxlDate ✓_ O y
I am exempt from t;le licensing requirements as I am a
licensed architect or a reg sten d professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 1051, Bus-
iness and Professions Code). �I PfcWT USSWNG PEE $
Lie.or Reg.No. __Date TOTAL FEE
HOME OWNTER-DUI:,DFR DECLARATION PLAN CHECK APPLICANT
I hereby affirm that i am exempt from- the Contractor's NAME o
License Law for the following reasoa (Section 7031.5, Busi- z 3,8,8 3 A
ness and Professions Code): ADDRESS # 0,0 0 o o 8
1, as owner of the pr opera};'will do the work and the
structure is not intended fir off.red for sale (Section 11CITY TEL NO. 2 010 3 5 0
7044, Business and Professions Code). I
ElI, as owner of the property, am exclusively contracting iiOWNER W; 'oo Yo 7j Q 0
with licensed contractors to construct the project i�MAIL ' !�/�f 1
(Section 7044, Business and Professioi-s Code). JADDRESS Q 8,3.0—8 4
CONSTRUCTION LENDING AGENCY IICITY TEL.NO.
I r the
yperfor that there is a kforuction lendinghagency IIC0NTRACT0R���
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). I—
Lender's Naini i�ADD RESS r,? ,Pp
Lender's Address II CITY fts'a I E.L.NO.����
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-7e CLASS
ordinances and State laws regulating Heating,'Ventilating and
Air Conditioning, nd 'iereby authori/e representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter r in a above-mentioned property for
in-•�er .on purpos ��
Signature of Per ttee Date
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