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WORKERS'COMPENSATION DECLARATION "CE-8-1 d (2 80) t 6�=�1 P P UC A T�®I V FOR P E R UGIT T
I hereby affirm that I have a certificate of consent to,self
insure, or a certificate of Workers'Compensation Insutance,or H EATING-V ENT ILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 ab C.) P `
Policy No Company 7A-7-C—
Certified copy is hereby furnished
COUNTY OF LOS ANGELES ' ° BUILDING ARID SAFETY
GCertified copy is filed with the county building inspection BUI LDING
department FOR APPLICANT TO FILL IN
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY �t p
COMPENSATION INSURANCE. NEAREST t
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST L CL
O
by the permit is for one hundred dollars ($100) or less) DISTRICT NO PROCESSE BY
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFMU
permit is i$sued, I shall not employ any person in any manner ��U 0
so as to become subject to the Workers' Compensation Laws BOILER,BTU
a APPROVALS DATE INSPECTOR S SIGNATgRE 1--
Date—
Date Applicant COMPRESSOR,BTUW
` -
ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM N
FINAL
Exemption, you should become subject to the Workers' '��' >• �..T` Z
Compensation provisions of the, Labor Code, you must forth-
with comply with such provisions or this permit shall"be EVAPORATIVE COOLER VALIDATIO
deemed revoked FURNACE 'FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter ' HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi WALL I—� �Q
ness and Professions Code, and my license is in full force and
effect^
License Numbe E>;40a27 Lic Class
Of
Contractor_ __rDate
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-,
ihess and Professions Code) PERMIT ISSUING
Lic or Reg No Date TOTAL FEE Q S'C�
HOME OWNER-BUILDER DECLARATION F PLAN CHECK APPLICANT _ �'O'6 O o'8
I hefeby affirm that I am exempt from-the Contractors NAME >-t R 4,� S 01-3 a Q t-4-/ /✓ � i
License Law for the following reason (Section 7031 S, Busl- r, i2t°io 2 0,J5 Q
ness and Professions Code) ' , ' ADDRESS
SI� '2 � ir2 i�- T- ,
I as owner of the property, will do the work and the ° ° ° 2 0.5 0 5
Structure is not intended or-offered for sale (Section CITYI e- L C j ?JEL NO
7044, Business and Professions Code) �. 0 A 1 9-8 4
aOWNER rJ. �25 CJ le :: t.t, ✓
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code) ADDRESS (�
CONSTRUCTION LENDING AGENCY CIT1l�/yj�� C f Y;rEL NO
I heieby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR i Q z �[ N \X
issued (Sec 3097,Civ C)
Lender's Name ADDRESS
Lender's Address 'CITY /OL/ TEL NO �a
1 certify that I have read this application and state that the STATELIC f
above information is correct I agree to comply with all County LICENSE NO �02 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
uispe n purpose
signature of Perm tee Drte