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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affYm t},at I have a certificate of consent to self
Insure, br.a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
76A364C
or a certified copy thereof (Sec 3800, Lab C )
TR r( '20.A41, CE-818(REV talar)
Policy No Company -
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT-TO FILL IN BUILDING
tion department ADDRESS
(PRINT OR TYPE ONLY)
Date j I ^ Appllcant '`.' - LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
ABSORPTION UNIT BTU DISTRICT NO P BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less )
AIR HANDLING UNIT CFM
I certify that in the performance of the work for which this
permit is Issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws BOILER BTU APPROVALS DATE IN PECTO SIG ATURE
Date Applicant COMPRESSOR, BTU ROUGH A I —�
NOTICE TO APPLICANT If, after making this Certlflcate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' '
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 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is In full force and effect >_
d
License Number J`���Z / Lic Class �— /D , U
Contractor(;�Y' I T Date
U
I am exempt under Sec utW
Plan check fee H
B&P C for this reason PERMIT ISSUING FEE a U Z
Date
Signature TOTAL FEE ��
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License A
Law for the following reason (Section 7031 5, Business and NAME ti p Z A L u N 14 �>d
Professions Code)
❑ I, as owner of the property, or my employees with ADDRESS P.d d 9 /6
wages os,their sole compensation,will do the work and CITYTEL NO �`C
the structure is not intended or offered for sale(Section
7044, Business and Professions Code)
OWNER
ElI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIADDRESS L ��Ar�S
5 9 4.,1 A
tion 7044, Business and Professions Code) ,
CONSTRUCTION LENDING AGENCY CITY TC� TEL NO
I hereby affirm that there Is a construction lending agency for ► # 0 0 0 0 0
the performance of the work for which this permit is Issued CONTRACTOR ^�7� r Q S7"
(Sec 3097, Civ C )
ADDRESS 2 7. 5 O .
Lender's Name x
CITY TEL NO _ o m o 2 7. 5 0 5
Lender's Address
STATE ' LIC 1, 1 4 ' 86
1 certify that 1 have read this application and state that the LICENSE NO 3G 6B Z CLASS +
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
upo the above-mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date '