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WORKERS'COMPENSATION DECLARATION APPLICATION .FOR PERMIT
I.,hPreby,_ZTffifm that I have a certificate of consent to self
insure,�r a certificate of Workers' Compensation Insurance,' HEATING.- VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec*3800, Lab. C. 76A364C
)' CE-818(REV 10/81)
K�cy No 7c�npany
Certified copy.is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the c un building inspec- FOR APPLICANT TO FILL IN BUILDING,
tion department ADDRESS. 1 0
(PRINT OR TYPE ONLY)
Date 2/2 2/�$licanr LOCALITY Tem 1 e City
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION'FROM WORKERS' NEAREST
COMPENSATION INSURANCE _0 CROSS ST
(This section need riot be completed if the work involved by ABSORPTION UNIT, BTU FROUGH
I / PROCESSE BY �I
the permit is for one hundred dollars-($100)or less.) �)
I certify that in the performance'of the'work for which this AIR HANDLING UNIT, CFM l��''
permit is issued, I shall not employ any per'son in any manner
so as to become sublect to the Workers'Compensation LOWS. _ BOILER, BTU OVALS DATE S CTOR'S SIGNA RE
Date Applicant 1 COMPRESSOR, BTU V
NOTICE'TO APPLICANT: If,•after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers:.
Compensation provisions of the Labor Code, you must forth-' EVAPORATIVE COOLER VALID "TION
with comply with such provisions or this permit shall be
deemed revoked ' 1 FURNACE. FAU G #ITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with-Section 7000) of Division 3 of the Business HEATER WALL
and Professions Code,and my license is in full force and effect 8d
nlet$ and- outlets p
.7 5 2 2 6 Lic. Class C 2 Q V
License Number 4 -
Env . Engoil. 092/22/88 O
Contractor Date F
I am exempt under Sec d
Plan check fee H
B.&P C for this reason #A
Date: PERMIT ISSUING FEE $
Signature TOTAL FEE TJ'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
t I'hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031 5,•Business and NAME
Professions Code)'
I, as owner of the property, or my employees with ADDRESS '9024A
E]
'wages as their sole compensation,will do the work and CITY TEL NO #fo e o o-e 8
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER C . R. C o l o n y l e,• 4 4 5 0
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the proleci (Sec- MAIL ADDRESS j o;e o ((_ �5 0 cz.�
tion 7044, Business and Professions Code) E .
CONSTRUCTION LENDING AGENCY • CITY T e fp 1 e C I t TEL NO- 0 2 2 3 F: 8 8
I hereby affirm that there is a construction lending agency for 44$'— 4$- ,
9 5
the performance of the work for which this permit is issued CONTRACTORE-n v I r o n itle n t a l E n g i n e e r i ng
(Sec 3097, Civ. C ). . Poplar
ADDRESS-
Lender's Name
Lender's Address
CITY Orange TEL NO 639-8281
TATE
LIC
I certify that I have read this application and state that the LICENSE NO 7 5 2 2 6 CLASS
C 2 '
above information is correct I agree to comply with.all County
ordinanc nd ate laws relating to building construction,
and her by ho ze.representatives of th�ecotunjuNoses
nty to enter
pan t e ab m ntl roperty f • SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agen _ Date