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DECL
Orm'th CtI have cerci cgte- f corfNn APPLICATI8N FOR. PERMIT
fi�rrS tha4 d have a certifjcate_of cotfsent to self
certificate of Workers Compensation Insurance,, HEATING.- VENTILAJING - AIR CONDITIONING
tifie copq'thereof (Sec. 3800, Lab. C.) CE-81 C _
�Q CE 818(REV. 10/81)
NO.� �P Company '3`TM F144NI-D COUNTY OF LOS ANGELES )!. BUILDING AND SAFETY
Certified copy is hereby furnished. .
Certified copy is filed with the unt Idin inspec-. FOR APPLICANT TO FILL IN BUILDING leo
tion department. (PRINT OR TYPE ONLY) ADDRESS Tr ul
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE GGG"'
CERT CAT OF EXEMPTI M RKERS' NEAREST t 1
COMPENSATION INSURAN CROSS ST. t[ -
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. l/ i PROCESSED BY
the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this , CCCJJJ
permit is issued, l shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSP TOR'S SIGNATURE
COMPRESSOR, BTU 00 ROUGH
Date Applicant
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 VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G
LICENSED CONTRACTORS DECLARATION FLOOR BTU (J
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. 9L
G O
License Number �� Lic. Class
Contractorogo sEju► "-`bate f-
4;
F.
(-am exempt under Sec.
Plan check fee
B.&P.C. for this reason PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME T
Professions Code): f
❑ I, as owner of the property, or my employees with ADDRESS
r wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
j
7044, Business and Professions Code). /� .� �%✓ „
OWNER. [ -
I ❑ I, as owner of the property, am exclusively contracting F
with licensed contractors to construct the project (Sec- MAIL. w p/l�
tion 7044, Business and Professions Code). A D D a.
R E SLf�
CONSTRUCTION LENDING AGENCY CITY 1&/ TEL. NO. $ Vol
I hereby affirm that there is a construction lending agency for
the performance of the work for which_ this permit is issued CONTRACTOR
(Sec. 3097, Civ. C:). �� � �� -
ADDRESS
Lender's Name """",,,,,���RE... (We 11
CITY ` TEL. NO.
Lender's Address
STATE LIC.
1 certify that I have read this application and state that the LICENSE NO. 41,Z CLASS
above information is correct. I agree to comply with all County'
ordinances and State laws relating to building construction,
and here ath ize r presen ives of this County to enter
upon th o - enti ed pr perty for inspecHIP'
, ros s; SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat re A Lica r Agent Date