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I 76A364CWORKERS'COMPENSATION DECLARATION CE-818 (2.80) APPLICATION
pPLICATIOp C R PERMIT
I hereby af.�m that I have a certificate of consent to self
insure, era certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
fjcerifieyl copy thereof(Sec.3800, Lab.C.)
Pmic,',"i Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
'R Ceiified'cUpy is hereby furnished. '
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
p
de artment. y �t
Dare Applicant - (PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. LOCALITY ��
TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST {� >_(This section need not be completed if the work involved ABSORPTION UNIT, BTU - CROSS ST. O
by the permit is for one hundred dollars (5100) or less.) 01STRI/gTNn. N,./ PRONo
SFBY U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM y�f / 'vx Q
permit is issued, 1 shall not employ any person in any manner cccJJJ v 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU -
�A �/��] )J .r,p /� III APPROVALS DATE INarECTOR'B SIGNATOR E W
Dar e/0�/j J_'J7P plican I#jeF4-%/— COMPRESSOR, BTU �r/—� _ 1,[,O BOUGH _ _ N
NOTICE TO APPLICANT: If, after making this Certificate ofZ
VENTILATION SYSTEM FINAL `f/Z`��V fI (�P"/'-
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: FAU -RAVITY_
LICENSED CONTRACTORS DECLARATION 1 FLOOR: BTU_
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNI3
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and '
effect. //�� /J 4
License NNummbea�1.:y_4 ff Lie.Ciass_C�^f^ v
Contra,-4,
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). PERMIT ISSUING FEE $ (
Lie.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS - ACCT•t
❑ 1, as owner of the property, will do the work and the ..
structure is not intended or offered for sale (Section CITY TEL. NO. 330 30.W7044, Business and Professions Code). 1 ITEMS
El I, as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project MAIL
TOTAL 30 :. 0
(Section 7044, Business and Professions Code). ADDRESS
CITY TEL.No. CHECK ��•
CONSTRUCTION LENDING AGENCY
30.50
I hereby affirm that there is a construction lending agency CHANGE .00
for the performance of the work for which this permit is CONTRACTOR
issued (Sec. 3097.Civ.C.).
Lender's Name _ ADDRESS
Lender's AddressCITY TEL _ 0000-0001 10/18/89
. NO.
I certify that I have read this application and state that the STATE -LIC. 6285 1 A1111:41
above information is correct.I agree to comply with all County LICENSE NO. CLASS -
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and herebv authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter U=n the above-mentioned property for -
inspection purpose
I�-
.,i r.uremit,e. Date