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WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I rhereby affirm that I have..a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING -'AIR CONDITIONING
CE-81
or a certified copy thereof (Sec. 3800, Lab. C
m o�37_�00 3 CE 818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnis ed. COUNTY OF LOS ANGELES B IDN AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion cipart nt. ADDRESS-
(PRINT OR TYPE ONLY)
Date 7L LOCALITY V�
�� lican App9& NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT,
BTU DISTRICT NO. PROCEss D B
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 v
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROvALS DATE IN CTOR'S SIGNATU E
Date Applicant COMPRESSOR,BTU r �� Q 6,o O '_ ROUGH — J
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' r
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER itAL&D AT N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUG AVITY /�
LICENSED CONTRACTORS DECLARATION FLOOR BTU L
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
Q �
License Nu er�� U Lic. Class ,
Contra ate a�/ # V
❑ I am exem under Sec. Y
Plan check fee a
B.BP.C. for this reason'
PERMIT ISSUING FEE $ d Q I
Date: o o 3 Q,5 Q
Signature TOTAL FEE r®
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o o o 3 Q 5 0 5
I hereby affirm that I am exempt from the Contractor's License ► 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 CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
❑ OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAILIr
tion 7044, Business and Professions Code). ADDRESS .7 Q
CONSTRUCTION LENDING AGENCY CITY TEL. NO.3O 7�
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit'is issued CONTRACT ,
(Sec. 3097, Civ. C.).
ADDRESS �3
Lender's Name p
CITY TEL. NO.
Lender's Address
STATE3a QnLIC. _ �O
I certify that l have read this pi tali and state that the LICENSE NO. (J p(o CLASS
above information is correc ag to c mply with all County
ordinances and State law relati to uiiding construction,
r h r ere resent ves f this County to.enter
t me ion d pro t or ins coon p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ig ture of A plicant or Agent ate
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