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WORKERS'COMPEi�SATION D�ELA'
ATION % A P P L1 C A I0N FOR ERiVIIT.
I hereb a`s4m tfat�y havfe`�a certificof consent t' self
insure, or a, er�lflcate of Workers' Coen--';on Insuj'ance, 76A364C HATING - VENTILATING - AIR CONDITIONING
or a certified cop thereof (Sec. 3800, Lob. C.) CE-818(REV. 10/81) 4� d
Obaa3-7-0003
Policy No. Company
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
IXI. Certified copy is filed with the county building i (spec- FOR APPLICANT TO FILL IN BUILDING
In
1� tion part ent. f?r (PRINT OR TYPE ONLY) ADDRESS
! Date �` SApplica LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
� 4
CERTIFICATE OF EXEMPTION FR WORKERS' NEAREST
COMPENSATION INSURANCE // CROSS ST.
(This section need'not be completed if the work if,/:Ilved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED v
the permit is for one hundred dollars ($100)or less.) �` //C•
AIR HANDLING UNIT, CFM (f o
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 f APPROVALS DATE PEC OR'S SIGNATURE
COMPRESSOR, BTU / �j u `0 ROUGHZL G
Date Applicant
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 VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUG VITY O
f 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 forceandeffect.
License Num er Lic. Class` U
Contract ate O�o�
�253,4A U
` ❑ I am exem t under Sec. UJ
Plan check fee $} o 0 0 0 0 $ #A
B.&P.C. for this reason' �
Date: PERMIT ISSUING FEE $ o I o - 30,50
Signature TOTAL FEE o 0 0 3 Q 5 0_v
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , o 7,25-85
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
E] 1,
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL.ADDRESS SCJ
tion 7044, Business and Professions Code). Jam—
CONSTRUCTION LENDING AGENCY CITY TEL. NO.3�J
1 hereby affirm that there is a construction lending agency for ,
the performance of the.work for which this permit is issued CONTRACTC
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS I- I
CITY TEL. NO. 3/ I l l
Lender's Address
STATE p LIC. /d Zo
I certify that I have read this applic Tion a d state that the LICENSE NO. Q CLASS C
dove information is correct. I agree t compl with all County
dinances and State aws rel n buil Ing construction,
a r4Lb r rese tati e of t s County to enter
n tion r per f sp coon rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa Urent or Agent D to