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WORKERS'COMPENSATION DECLARATION CEA 818 (2.80) f•'Sl P P L IC k T U®N FOR P E R M PT
I hereby-affirm that I have a certificate of consent to self
insure, or a certificate of Workers',Compensation Insurance,or `_ 'HEATING-VENTILATIR�G-AIR CONDITIONING
a,certified copy thereof(Sec 3800, Lab C) s
Policy Company_, ��'_ COUNTY�OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is-hereby furnished. r
'❑ CertUfied copy is filed with the county bi l� nspectwn BUILDING'
de�artmenr _ FOR,APPLICANT TO FILL IN'' ADDRESS, 14Q y115—j �f+ /mss
Date Applicant- = (PRINT OR TYPE�ONLY)
LOCALITY
CERTtIF[CATE OF EXEMPTION FROM-vYORKERS' _ NO - TYPE,OF'APPLIANCE'OR EQUIPMENT '�' FEE NEAREST_ r
COMPENSATION IN§blkANCE' _ q CL
•`(This section'need not be COinpleied if zthe work involved ABSORPTION UNIT, BTU CROSS ST - 0
by the permit• is for One hundred dollars ($iOO) or less.) _ - - "DISTRICT No - IV -PRDCESSE 11Y ' 'r -V
I certify that in the performance of the work for'which'thisAIR HANDLING°UNIT,CFM O
°permit is issued, [shall.not employ any person in anyamanner
so as to becoihe subject to the Workers"Compensation Laws BOILER,•f�TU' ` r
-^ Y i•, s w .� i APPROVALS DATE INSPECTORS'SIGNATURE -U
UJ
Date -Applicant COMPRESSOR,BTU �' ROUGH - d _
- Cl)
NOTICE TO APPLICANT If, after making this Ceitificate ofVENTILATION SYSTEM FINAL
_ - I "��`-��
Exemption, 'you should become subjectrto the Workers' _ 3
Compensation provrs`ipns of the Labor Code, you must forth- _
rwith comply with such provisi ns or,'thts' permit shall"be r , EVAPORATIVE COOLER VALIDATION
deemed revoked
, FURNACE
CE -'FAP GRAVITY—
LICENSED
RAVITY LICENSED CONTRACTORS.DECLAP ATION FLOOR ��11 �•
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT `
9 (commencing with Section 7000) of Division 3 of the Bust- - ' ! WALL
ness and Professtons-Code, and+my 11cense'is in'full force and a
effect
Licepse Number_ L i c Class —.2 _
Contractor f. �°1�- Date
❑ „y
I exempt,from .he licensing requirements as I am a . s
licensed 'architect'or a registered professional',engineer . x Plan check,fee 25%of above
actitik in'my,professional capacity (Section 7051',cBds- °
mess and Professions Code) ' ' '° PERMIT ISSUING FEE $ i
Lid or Reg NoDate �` TOTAL FEE' j7
"
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, Bust-,
} 'ness'andProfessionsCode) , ADDRESS` w
r,
❑ I,_as owner of'the property, will do the work and the TEL NO R
structure'is ,not,intended or,offered fur sale (Section CITY
7044,Business,and,Professions Code) „ R 2;541`4A •
OWNER'
I, as owner of'the property, am exclusively contracting L/i���'N'l��l✓'
-With contractors,to construct the project MAIL ;�° � , 3 •; , a'
`
(Sect ion'704'4; Business and Professions'Code) ADD RESSt __weZA4,0 a� <
” CITY, TEL.NO t�j -,�$v 2,-'- 2 7.O O
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction'lending agenc'y - ;° 0
'0 2 7 0 0':c
for,'the performance=of'the,work for which this permit is CONTRACTOR�� �y g , P e.
issued(Sec 3097,Civ.C) 27
8
Lender's Name ADDRESS All' L h.
Lender's,Addre%ss CITY TCL NO �� O
I certify that I have read this application and state that the STATE 'LIC /
.above information is correct I agree to comply with all County LICENSE NO 3d '� :'CLASS '�- "� ,
ordinances and State Iaws,regulating,Heating, Ventilating and w
Air'Conditioning, and hereby authorize representatives of this SEE,REV,ERSE FOR EXPLANATORY LANGUAGE
County to- ent i pon the above-mentioned property for o
w �e� on pur y
4
a��. � _ '
Signature of PF mi a .Date'