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'WORKERS'COMPENSATION DECLARATION CEA 64 (2-80) Q I p��C� °,`�S O N G OO R p C R M ff
I hereby affirm that I have t certificate of consent to self
insure, or a certificate of Workers' ompensation Idsurance„or HEATING-VENTILATING-Al R .C6NDOTIO ON6
I,�a cPrttfijo tefe� / e30C,Lab.C.
f`p 11Y Company )
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certi�Ied 'op};is filed with t,e ccvr ty bu+.ding inspection BUILDING
,ep:/.t.. e.tt.i/ ®P$ APPLICANT TO FILL IIS! ADDRESS �l`aU / ( .
Date_ / Applicant _ (PRINT OR TYPE ONLY)
LOCALITY 'Tl f/4f
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE Ll
COMPENSATION INSURANCE NEAREST }
(This section need not be conn leted _n ?he work involved ABSORPTION UNIT, BTU CROSS ST. 0
O
by the permit is for one hundred dol.2S ($200) or less.) DISTRICT NO. PROCESSED BY (�
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM /
permit is issued, I shall not employ any person in any manner ' 1 J�fJ e ! O
so as to become subject to the Workers' Compensation Laws. I BOILER, BTU (—
APPROVALS DATE INSPECTOR'S SIGNATURE IU
Date Applicant I COMPRESSOR, BTU
ROUGH z
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL
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 1 am licensed under provisions of Chapter I HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions (yde, a ,d y license is in f fll force and
effect. L I.YY C��
LicenseN her �ll ,Lic.Class J �i� iE—���L�� v
Contrac � _�.�•+oL.V� .3ate.
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-
iness and Professions Code). i' PERMT ISSUING EEE $
Lie.or Reg.No. Date TOTAL (FEE
HOME OWNER-BUILD T�R DECLARATION �I PLAN CHECK APPLICANT
i
I hereby affirm that I am exempt from the Contractor's I NAME
License Law for the foIlo%ving reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
❑ I, as owner of the property, will do the work and the TE L. NO.
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code).
❑ OWNER _
I, as owner of the property, am exclusively contracting z Q''1 �LI.�5'A
with licensed contractors to construct the project MAIL t, J-�
(Section 7044, Business and Professions Code). ADDRESS V� l #`0;0j'0to (l 1
CONSTRUCTION LEIsIDING AGENCY ^ CIT TEL. NO. ti ,
I hereby affirm that there is a constructionlending gene 2j°#°t23.00
for the perfor -e of the. wor fo which this pe,mit s I CONTRACTOR
issued(Sec. 309/,C ). 'o °)o,2`7,0 0
_ _
Lender's Name-%,- !_ — _ ' ADDRESS
Lender's Address
—a
LG —__ _ Y Sv EL.NO.��
I certify that I have read this application and state that the STATE o LIC. C
above information to correct. I agree to comply with all County LICENSEc � I CLASS�iW
ordinan s a d Stat. laws regulating Heating. Ventilating and
Air Co dition I g, a d hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Coul • to f-ter upon theabove-mentioned above-mentioned property for
insp c ion ar a' S.
Signature of Permittee Date