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WORKEKS'4--OMPENSATION DECLARATION /,� l�l�ll ��/� 1��®ftp 12®Ili fo72(�(a(1�5� �---
y affirm that I have a certificate of consent to self b'�i11T U"L� !i-�l 11 N FOR lr LS II�CM Il
1- or;c certificote of Workers' Compensation Insurance, HEATING - VENTILATING - l4'I� CONDITIONING
or a certified copy thereof (Sec 3800, Lab 'C ) 176A364C
' !eS ,CE-818(REV 10/81)
Policy No777A7Ao3CompanyTN�/1 05 l
Certified copy.is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
j
® Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
ADDRESS L/r
Date Applicant
tion department
�— �' (PRINT OR TYPE ONLY) 111,1:4 ell
1 LOCALITY 'T� � �+1. -•,�
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU V DISTRICT NO PROCESSED BY
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner,
so as to become subject to the Workers'Compensation Laws BOILER, BTUI APPROVALS DATE INS CTOR'S SIGN TURE
Date Applicant COMPRESSOR, BTU r ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become 'subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such provisions or this permit shall be
deemed revoked 1 FURNACE FAU G[AOVIITTY fig
LICENSED CONTRACTORS DECLARATION r FLOOR BTU 1
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
`/ C39 Scdlo 0
License Number 7d073•5 Lic Class SC 4 D V
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Contractor �U�y'1 IZ `7/C- Date b �ocJf`d 7 O
❑ I am exempt under Sec W
Plan check fee d
B &P C for this reason H
Z
Date
PERMIT ISSUING FEE $ 0
'
Signature ; TOTAL FEE Q e
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's LicenseD _-T 2 3 7, A
Law for the following reason (Section 7031 5, Business and NAME
Professions Code) I # 0 0 0 0.0 8
El1,I, as owner of the property, or my employees with 2 0.0 3 O,5 0
wages as their sole compensation,will do the work and CITY TEL NO i
the structure is not intended or offered for sale(Section o 0 0 3 Q,5 O mu
7044, Business and Professions Code) l L Z9—�]Q
[�
❑ j, as owner of The property, am exclusively contracting OWNER f' 0 (�
'With licensed contractors to construct the project (Sec- MAIL /
tion,7044, Business and Professions Code) ADDRESS to e
CONSTRUCTION LENDING AGENCY CITYems, �+• TEL NO �7 O J7
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR �G C C
1�� TiVC
(Sec 3097, Civ C ) / D ;
ADDRESSC%N%
Lender's Name
CITY �'7 TEL NO
Lender's Address TG//,t �e
STATELIC C3 g sC,ZD
I certify that I have read this application and state that the LICENSE NO, ,O37 CLASS
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
and hereby authorize representatives of this County to enter
u n the above-mentione perty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _
0/ 020� �Y
Signat a of Applicant or Agent Date '-