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WOR KGR5`COMPENSATION DECLARATION" CE 818 (2-80) Gil IF—' tom- C AT D O U`�1 FOR
USS' lf—FFD)ERWT
I hereby affirm that I have a certificate of consent to self
insure, or a`'certifica e—bf Workers'Compensation Insurance,or HEATING—VE TING-AIR CODNDITIONING
a certified copy thereof{Sec.3800,Lab. C:)
Policy No: Company �-
0 -Certified copy is hereby fu '0 Es i?,-
// COUNTY OF LOS ANGEL\✓vv/ ` BUILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING `P
departrrignt. FOR APPLICANT TO FILL IN
ADDRESS ��
Date Applicant (PR,INT OR TYPE ONLY) }+
LOCALITY�.�`"
CERTIFICATE OF EXEMPTION FROM WORKERS' N66
O. TYPE OF APPLIANCE OR EQUIPMENT FEE /- ���
COMPENSATION INSURANCE NEAREST
R
COSS-ST."
(This section need not be completed if the work involved ABSORPTION UNIT,BTU tl
by the permit is for one hundred dollars ($500) or less.)- _ olsrarcTNO. JPRI,-SSEIJBY O
l certify that in.the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall hot employ any person in.any manner _ _ Q
he Workers Compensation Laws. BOILER;=BTU
O,
so as-to become'subject to f APPROVALS DATE wsPECToa's51 •^.ATUAr U.
1
Date Applicant (` GOMPRESSO'R,BTU LtJ
NOTICE TO-APPLICANT -' , m�f aking this Certificate of VENTILATION SYSTEM y ` Z
ROUGH {p^ �✓
Exemption, you should oecome subject to .the Workers' FINAL ' m _
Compensation provisions of the Labor:Code, you must forth- EV APORATJ V E COOLER "
with .comply with such provisions or this permit shall be VALI-D/XTaO
deemed revoked. FURNACE: ., FAU ' GRAVITY
LICENSED C`O"NTRACTORS.DECLAP ATION FLOG R: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7QOo)of.Division 3 of the Busi- WALL
`• ness and.Professions Code, and my incense is in.full force and% '
effect.
'License Number_ Lic.Class
Contractor— _ � Date
licensedI am earchitecmorhalregistered requirements.as I'am�a
-professional engineer Plan-Check fee 25%Of-above:
acting. in my .professional capacity(Section 70.51.,'Bus-
inessand.Professions-Code). PERMIT ISSUING FEE;$
Lie.or Reg.No. .Date TOTAL FEE
ROME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I' hereby affirm that 1 am, exempt from- the.Contractot's _ -NAME . �" T � ,�( �f�.��b �rA
License Law for the following reason (Section 7031.5, Busi= h oho,
ness and-Professions Code): I ADDRESS 8
0 0
I as own of the property, wild da.the work and the - 2ii�t" �. .2 o ro 5 0•'
CITY_ Nq
structure is not intended or offered' for sale (Sectiou� - � .� :.9/T�P'S �i/� ��
7044, Business and,Professions Code). Ierote
I, as owner of the property, am exclusively contracting
OWNER �� �1 /?� �� ;
/ ! (� r !�5
with licensed contractors to construct . the, project " MAIL f t 2 8' $"2 "
(Section.7044, Business and Professioas Code).' ADDRESS cJ iQ 1 n
CONSTRUCTION,LENDINQAGENCY CITY TE L. ` f�
I hereby affirm that there is a construction lending agency "
for the performance of the work for which this'permit is .- CONTRACTQR
issued(Sec. 3097,Civ.C.).
L'ender's Name . f/ ;f/_��/ - ADDRESS
Lender's Address <!_�.ti CITY .TEL.NO.
I certify that I have read this application and state that the STATE LIC.
Lr
above information is correct.I agree to comply with all County LICENSE NO. CLASS y
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the"above-mentioned property for
inspection purposes.ir
a lJ
" ralgnlat�.,e or Permittee Date .