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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate-of,consent to self
��rsure, or 0 certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR .CONDITIONING
or a certified copy thereof (Sec. 3800, L b. C.) 76A364C
CE-818(REV. 10/81)
Policy No. �' Company _ . COUNTY OF LOS ANGELES BUIL G D SAFETY
Certified copy is hereby furnished:
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. / (PRINT OR TYPE ONLY) ADDRESS P VlJ
Date O ; Applicant egis A11 i LOCALITY �� e
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
C RTIFI ATE OF EXEMPTION FROM WORKERS' NEAREST /
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved by'
the permit is for one hundred dollars $100)or less.) �j
AIR HANDLING UNIT; CFM � (�
I certify that in the performance of e work for'which this '✓`
permit is issued, I shall not emplo any person in any manner
BOILER, BTU
so as to become subject to the orkers'Compensation Laws. �J/g1 �j/y APPROVALS DATE INS CTOR'S SIGNATURE
COMPRESSOR, BTU � 0O [(J (/V ROUGH
Date Appl' ant
NOTICE TO APPLICANT: , after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you shou become subject to the Workers'
Compensation provi 'ons of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with. comply with ch provisions or this permit shall be
deemed revoked. FURNACE: FAU G V1zY �d
LICENSED CONTRACTORS DECLARATION FLOOR BTU V o
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.
//7 O
License Number 073 Lic. Class �'�� h ►
Contractor Date 10
IJ-0
�
F-1V
I am exempt under Sec. �e �Y� w
Plan check fee H
B.BP.C. for this reason PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE S� e
�3 2 6 2-A
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License # o o 0 0 0 8
Law for the following reason (Section 7031.5, Business and NAME ► ( o o44.50
Professions Code):
ADDRESS
❑ I, as owner of the propert or my employees with x
wages as their sole compe ation,will do the work and o 0 0 4 U 5 0'�
the structure is not inten d or offered for sale(Section CITY TEL. NO.
7044, Business and Prof ssions.Code). ( 0.2 -$Jr
OWNER
❑ I, as owner of the or perty, am exclusively contracting
with licensed cant ctors to construct the project (Sec-
ADDRESS
tion 7044. Burin s and Professions Code). ADDRESS
CONSTR TION LENDING AGENCY CITY TEL. NO. �-
I hereby affirm that t ere is a construction lending agency for
the performance of the work for which this permit.is issued CONTRACTORirj ►
(Sec. 3097, Civ. C.).
ADDRESS -Zb ca
Lender's Name
CITY Z� TEL. N
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
O . y&S
Signature of Applicant or Agent ate