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WORKERS'COMPENSATION DECLARATION CEA 818 012 8P) APPLICATION FOR -PERMIT
I hereby affirm that I have r certificate of consent to self
insure, or.'e certificate of Workers'Compenutlon Insurance,of HEATING-VENTILATINGAIR CONDITIONING
a certlfled copy thereof(Sec.3800,Lab. C.)
Polley No. Company
❑ Ce�tlfled copy.Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
® Cartlfled copy is filed with the county building Inipectlon BUILDING
department. FOR APPLICANT TO FILL IN
Date Applicant LOCALITY OR TYPE ONLY-) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM'WORKERS' NO. TYPE O-F APPLIANCE 04h EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need not be core leted if'the work Involved ABSORPTION UNIT, BTU CROSSST. [�
by the permit Is for one hundred dollars ($100) or leu.) PISTR1CTr4o, PRoc v
I certify that in the performarKe of the Work for which this AIR HANDLLNO UNI CFM,
permit is issued, I shall not amp] y y.p any manner
so v to'become subject to th o pe tion Laws. BOILER, BTU
APPROVALS DATE• irtr3PEcroRa eiorvATURt:
Date_ Applicant. OOMPRESSOR BTU ROUGH
NOTICE TO APPLICANT: kfter'meking this CertlRate of VENTILATION'SYSTEM
Exemption, you Gould zrt subject to the" Workers'. FINAL
Compensation provisions'of the Labor Code, you must forth- '
ORATIVE CObLER
,with comply with such provbions or this permit shall be' EVAPVALIDATION
deemed revoked. t FURNAUE•' FAU- GRAWTY
LICENSED•CONTRACTbRS DECLARATION FLOOR: BTu
I hereby affirm that I ■m lkbnsed under Orovtsions of Chapter HEATER: 8 NDED UNIT i
9 (commencing with Section 7000) of•Divfslon 3 of the Busl-,
ness and Professfons Code, and my license is In full force end ,
affect.
Llcerise Nu or Lie. Clsis
Contractor Date
I • xempt from the pcerutng requirements as I ■m a
l ll afchltect or Y registered ptofessional enirineer Plan Chi a fee 25% of above.
I acting In my professional capacity (Section 7051, Bus-
Ineas and Professions Code). PERMIT ISSUINQ FEE$
Lic.or Res.No. Date TOTAL FEE .
HOME OWNER-Bi.SiLpER DEC.L'ARATION-, PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
1393.6'A
License- Law for the followipg reason (Section 7091.5, Bust-
new and Profeuiow Code): ADDRFSS #lo o • • •,8
❑ 1, u owner of the propotty, will do the work and the TEL. NO. 21- • 2�Q 5 Q
structure L not intended or offered for sale (Section CITY
7044, Business and ProfeWons Code).. OWNER ° e e 2 Q 5 4 E
❑ I, as owner of the property, am exclusively Contractlng r ,
with heats contractors. to construct the project MAIL 07,26-83
ADDRESS
(Seetlon 7044,Busineu.and Professions Cede).
CONSTRUCTION LENDING AGENCY CITY. TEL,NO' Z 2
I hereby affirm that there is e"construetlon lending agency
for th performance of the work for which this permit Is CONTRACTOR'
issued Sec. 3097,C,Iv.C.).
Landers Name ADDRESS
Lender's Address LICENSE
ITY TE L..NO.
I certify that I have road this application and state that the
TATE LIC.
above information is correct. I agree to coptply with ell County CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FORF-XPLANATORY LANGUAGE
Count to enter u the above-mentioned property for
i,u ur
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SI of PaTmittea fe