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WORKERS'COMPENSATION DECLARATION '76A3640
CEA 818 i2-80) G J If l� ��/�1 O Il�l FOR If� lf�S UVU ��
I hereby affirm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,of
a certified copy thereof(Sec.3800,Lab.C.)
Policyrti Company
El Certified copy is hereby furnished. COUNTY OF LOS ANGELS BUO LDONG AND SAFETY
Certified copy is filed with the county building inspection BUILDING c
department. i�08�'A NT OR ill PEO LY) 6�1 ADDRESS �j l
Date Applicant
(PRINT OR TYPE ONLY) /-��� r`"�-Q�
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST t C }
CL
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. _i2�f_l�t�t-�� O
by the permit is for one hundred dollars ($100) or less.) DISTRICT No. / PROCE- ^By U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
S O
permit is issued, I shall not employ any person in any manner O;e
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
aat�r�p�/� APPROVALS DATE INSPECTOR'S SIGNATURE lLIU
Date - Applicant —LCOMPRESSOR,BTU--cJ �-LrVV !� - ROUGH .,� CL
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z
FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be yy
deemed revoked. FURNACE.: FALl1_ GRAVITY
LICENSED CONTRACTORS DECLARATION L FLOOR:
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number_ Lie.Class
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). � I
Lie.or Reg.No. Date TOTAL FES
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME _Q
License Law for the following reason (Section 7031.5, Busi - -
ness and Professions Code): ADDRESS �c—� �v�Q� � z 5 9 4.5 A
I, as owner of the property, will do the Work and the CITY TEL. NO_ # o 0 0 0 0 8
structure is not intended or offered for sale (Section -
7044, Business and Professions Code). ) '
OWNER A ,pp/� 2 0 0J�'Jr Q' .
I, as owner of the property, am exclusively_contracting , �,f _,/{�_ _ .!_'`'_� /l✓L-I-
with licensed contractors to construct the project MAIL �n �,,,r7� ;o 0 0 3$ 5 0 55
(Section 7044;Business and Professions Code). ADDRESS GL l �� __t . � « _
CONSTRUCTION LENDING AGENCY CITY`T r ec/ 1 TEL NO.' a,
I hereby affirm that there is a construction lending agency / °�✓ ! '/� !✓`�+ �O
for the performance of the work for which this permit is CONTRACT
issued(Sec. 3097,Civ.C.). C�vr�•!L
.Lender's Name ADDRESS
Lender's Address CITY TEL. NO.
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. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,andrereby authorize representatives f this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ems"' u ion the above-menfioned prop"
iy for
insnP ...on r,rpo.-s. t`
Sig,afore of Permittee Date