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WORKERS'COMPENSATION DECLARATION ICE 81 C APPLICATION
P 1� p y N F PERMIT R M
I hereby affirm that I have a certificate of consent to self CE-818 (2-80) P`l If� r IC YY 1 (O1 tl r O r IG IfR ItlY ��
insure, or a,certificate of Workers'Compensation Insurance,of HEATING-VENT ILATI NG-AIR CONDITIONING
a certified copythereof(Sec. 3800,Lab. C-.) v .J
Policy No.y�s�.��2.;ompany.Sa/C��W`ea
❑❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�! Certified copy is filed with the county big h' ag inspection' BUILDING
Dm departomen? ��.H/fa_ FOR APPLICANT TO FILL IN ADDRESS ,�o. SSS La ,POsa
Date> /-CU Applicant c.�sti(, �r.r.=�� (PRINT OR TYPE ONLY)
'LOCALITY
CERTIFICATE OF EXEMPTION FRJM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST >_
CROSS ST. Ard EN - d
(This section need not be completed if the work involved ABSORPTION UNIT, BTU O
by the permit is for one hundred dollars (SI00) or less.) DISTRICT NO. PROCESS r- ay U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit i5 issued. I shall not employ any person in any manner O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU 1H
APPROVALS DATE INSPECTOR'S SIGNATURE W
�y
Dale Applicant COMPRESSOR,BTU �oD � ROUGH '�- C'J" y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM/ FINAL ✓�®'� �`!' Z
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: FAUOg— GRAVITY j
LICENSED CONTRACTORS DECLARATION FLOOR: B7J
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect yy 77 C/ r
License Numbers,'1_44_ �/— Lic.Class`� C)
Contractor-Ga->S� G Date
❑ I am exempt fium 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 $�
Lic.or Reg.No. Date TOTAL FEE I y
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
❑ 1, as owner of the property, will do the work and the TEL. NO.
structure is not intended or offered for sale (Section CITY #�• o e e 08
7044. Business and Professions Code). {}� '
OWNER ! /Y' 't e e 3 O.,J 0
r_1 .
I, as owner of the property, am exclusively contracting talvelV�leltL�lO_Y_/.lr ,
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS .o,e e 3 Q,5 0 mQ
CONSTRUCTION LENDING AGENCY CITY TEL. NO. O•Q.1.0-83 "
I hereby affirm that there is a construction lending agency b -
for the performance of the work for which this permit is CON TRACTOR
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
2a_c N �%a_i_9v�r
Lender's Address CITY /7 TLS. NO.g/,,
I certifythat I. have read this application and state that the
pP STATE �SdS�l9 LIC.CLASSC�40 .20
.
above information is correct. I agree to comply with all County LICENSE NU. J 7
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorizerepresentatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE -
County to ente• pon .the above-mentioned property for
insnec�tio�n�spurpr
Signature opr .mi a Date