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�,. WORKERS-(OMPENSAIIONDECLARATION CEA 818(2-80) APPLICATION FOR 'PERMIT
I hereby affirm that Ihave a' certificate of consent to self
insure, or a certificate of Workers'Compensation
�y Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a c ertifietife M (Sec. 3801? Lab.���)'f
Policy No. Company
0 Certified copy is hereby furnished. COUNTY OF LOS ANGELES 13101 WING AND SAFETY
eP�j n FOR APPLICANT TO FILL IN ADDRESS
e��ertified copy filedwiththe cot�buil �iis ection '- (PRINT OR TYPE ONLY) - � � •
P y P BUtLbINGDatr
nt
s is
LOCALITY
�F�f` , P + 7 H
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE a NEAREST CL
(This section need not be completed if the work .involved ABSORPTION UNIT, BTU _ CROSS ST,
by the permit is for one hundred dollars. ($100) or less:) Dl RI&NO PRDc BY
AIR HANDLING UNIT,CFM = t W
-1 certify that in the performance of the;yyork_for which this - .� •. I�+( J
permit is issued, I shall not employ any person in any manner r LL
so as to become subject to the Workers' Compensation Laws. BOILER, BTU '
APPROVAL;S DATE INSPECTOf16SIGNATURE �.
Date Applicant COMPRESSOR,BTU 't t L
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL O
CL
Compensation provisions of the•Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or-'this-permit shall be _
deemed revoked. I FURNACE: FAU QFK.VtlTNi-- .00
LICENSED CONTRACTORS DECLARATION FLOOR' BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
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.
Licg,nse Number IK Lie.Class t' �¢
Contractor Date r rfp ;li rt'
ElI 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- ;
mess 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
I, as owner of the property, will do the work and O the structure is not intended or offered for sale (Section CITY TEL:NO.
7044, Business and Professions Code). Sl
I,.as owner of the OWNER ,l/.: tJt iP'/:
'. property, am exclusively contracting
with licensed contractors to construct the project MAIL0' TIT
}
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY
CITY .J! 1;"ydr 'I TEL NO. `.
I hereby affirm that there is a construction lending agencyf
for the performance of the work for which this permit is CONTRACTOR(",.,; V,1► < r"t '�';
issued (Sec.3097,Civ,C.).
Lender's Name ADDRESS �f'i, / ✓ 'M' ".�Pr ./. r�
Lender's Address CITY 1 `r`i. JFK a�; TEL.NO. ff b
1 certify that I have read this application and state that the. STATE 'i ' LIC. C JY
aboye information is correct.I agree'to comply with all County LICENSE NO. `� CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,andherebyauthorize representatives of this SEE'REVERSE FOR EXPLANATORY LANGUAGE
County to enter a on the above-mentioned property for
t e��pur os
Signature of Permittee Date