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WOR KERS'COMPENSATION DECLARATION CEA 818 (2-80) A P P UCAT�O Cl FOR R Ir"E R INtl T
I hereby at';cm that I have a certificate of consent to self
inse�,or a certificate of Workers'40olensation Insurance -)r p�EATING-VlENTILAT'IWG-AIR CONDITIONING
a certified -Irry thereof(qe�0C)Policy Nod op 7�c/mpany— -- COUNTY OF LOS ANGELES BUILDING AND SAFETY
0 Certified copy is hereby furnished.
1_ Certified cony is feted wah+he out' building inspjtt� FOR APPLICANT TO FILL IN BUILDING
depa-tr Pn+ _�r�� ADDRESS (7
/ (PRINT OR.TYPE ON
Date _ Appheant _ __ _ .
LOCALITY
CERT-Wit ATE OF EXEMPTION FRt'',WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _
COMPENSATION INSURANCE NEAREST, - t a}
(This section need not be completed i( the work involved ABSORPTION UNIT, BTU CROSS ST
by the pe-mit is for one hundred dollars ($100) or less.) DISTRICT NO �^ PCESSED
ROV
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM J`UJ
permat is issued, I shall not employ any person in any manner !/ 0
so a�to become subject to the Workers' Compensation Laws BOILER, BTU ,/ //qq APPROVALS DATE INS r ECT SSIGNAT E W
[late Applicant f CL
COMPRESSOR,BTU TJ�� �v ROUGH � /f I
NOTICE TO APPLICANT: It, after making this Certificate of v VENTILATION-SYSTEM FINAL zi�<o —
Exemption, you should become subject to the Workers'Compensation'provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIGN
wrth'comply with such provisions or this permit shall be M
deemed reioked, FURNACE. FAU "/GRAVIT-Y
LIC ENSFp'CONTRACTORS DECLARATION FLOOR BTU J
I hereby affirm that 1 am licensed under provisions of Chapter HEATER- SUSPENDED UNIT
3 (conrmericeng with Section 7000)of Division 3 of the Busi- WALL .
ness and Professions Code, and my license is in full force and
effect. -
1' mise Nuraberr!`�/ f�Lie,,.�CJass�
I am exempt from the licensing requirements as-I am a
iicsn;ed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- PERMIT ISSUING FEE 1 jl �C�
iness and,Professions Code}. ,
i
Lie.-or Reg No.- Date TOTAL FEE so
HOME OWNER-BUILDER DECLARATION PLAN CH E .K APPLICANT
I hereby affirm that I-am exempt from-the -Contractor's NAME 0�= /'f'
License Pro for the ode): Ing reason (Section 7031.5, Busi-
ness and Professions Coda � ADDRESS GL�L.fY-
• o • • •
.,� i, as owner of the prgperty, will do the work and the '
structure is not intended or offered for sale (Section CITY TEL. NO. a ..�/iy� :� • e 3 a 5 0
7044, Business and Professions Code). • * ? 3Q505
5
OWNER
1, as owrner of'the property, am exclusively contracting v _ _
with licensed contractors to construct the project MAIL R
(Section 7044, Business and Professions Code). ADDRESS6 J ! _ —- �• 1 1,25»8 5
GCITY
OCs
NSTRUCTION.LENlliN �AGENCY � TEL.N0.'A —tL//
I Itere�)y affirm that there is a construction lending agency — -
for 'tile pefiormance of the work for which this permit is CONTRAC-
issued(Sec 3397,Civ.C). _� /
Lender's TJziue ADDRESS n/J���
Lender's Address CITY TEL.NO�Yi //i2
1 certify*hat I have read this application and state that the STATE �- LIC. /U�� `��
above information is correct. I agree to comply with all County LICENSE NO.' _ f �_� CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditinniing, and.hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
C i nts to eaitcr upon theabove-mentioned property for
r t poses.
�ignarure
19,
f Pe ,attee Date