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WORK;RS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby afftrgt that I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C 76A364C HEATING - VENTILATING - AIR CONDITIONING
)
CE 818(REV 10/81)
Policy No Company
Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY /�
r_1 Certified copy is filed with the county building Inspec FOR APPLICANT TO FILL IN BUILDING a 5 Q / 6� �
4 � /`1
tion department (PRINT OR TYPE ONLY) ADDRESS I �i
Date Applicant
LOCALITY t
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 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 i/
permit Is Issued t shall not employ any person in any m ner
so as to become subject to the Workers Co en atio BOILER BTU APPROVALS DATE INSP OR S SIGNATU E
Date10. 1.5. F, cant N COMPRESSOR BTU ROUGH
NOTICE TO APPLICANT If aft making is Certif a of VENTILATION SYSTEM �Q B D FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLERU VALIDATI # 1 0 0 Q
with comply with such provisions or this permit shall be n ;(�
deemed revoked FURNACE FAU GRAVITY_r 1 • • Q u
LICENSED CONTRACTORS DECLARATION FLOOR BTU • • •1 Q 0 0
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPtNDED UNIT ' 5 Q
(commencing with Section 7000)of Division 3 of the Business Q 5a87
and Professions Code and my license Is in full force and effect
d
O
License Number Llc Class , V
Contractor Date 0 O
❑ I am exempt under Sec 8
Plan check fee W
B 8P C for this reason PERMIT ISSUING FEE$ Z
Date # • • • •,• 8
Signature
TOTAL FEE .S
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License w!
Law for the following reason (Section 7031 5 Business and NAME /•
Professions Code) 8 1 a 4A
❑ I as owner of the property or my employees with ADDRESS /2,02-S G S 4
wages as their sole compensation will do the work and CITY A-Z (15 TEL NO 6�`v/ 2� 1 • * 3G50
the structure Is not Intended or offered for sale(Section
7044 Business and Professions Code) OWNER • *431250
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL ,1 Q 2 3,�'8 7
tion 7044 Business and Professions Code) ADDRESSC.17-
CONSTRUCTION LENDING AGENCY CITY G� c f'� TEL NO
I hereby affirm that there is a construction lending agency for Poo performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Civ C )
ADDRESS
Lender s Name
CITY TEL NO
Lender s Address
STATE LIC
I certify that I have read this application and state that the LICENSE NO CLASS
above information Is correct I agree to comply with all County
ordinances and State laws relating to building construction
and hereby authorize represe tatives of this County to enter
upon the ob9fe mer}tioned erty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant Jr�Ag2g Date