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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified co y t ereof(Sec 3800 ab C ) CE_Big(REV 10/81)
Policy No
❑ Company Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
MCertified copy Is filed with the county building mspec- FOR APPLICANT TO FILL IN BUILDING
tion department ADDRESS
(PRINT OR TYPE ONLY)
Date 1-5 'g-7 ApplicantZLOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE v
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
D B
(This section need not be completed If the work involved by ABSORPTION UNIT BTU DISTRICT NO
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 1 (1
permit Is Issued, I shall not employ any person In any manner
043
so as to become subject to the Workers'Compensation Laws BOILER,BTU /,Q 'l APPROVALS DATE I OR S SIGNATURE
Date Applicant COMPRESSOR,BTU W100 ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' &1Z Z—JF21
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU V G VIN
LICENSED CONTRACTORS DECLARATION FLOOR —BTU���
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 d
10
License Number 4% L¢ CIaSS e-a V V
61 ate 1'S97 O
0
Contracto
�
❑ I am exempt and Sec 6 2 7 A IL
Plan check fee
B 8P C for this reason PERMIT ISSUING FEE$ Z
Date I • • 4•a 0
•
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT TOTAL FEE • • 4 a 0 0 5
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 5, Business and NAME Q 1- 0 5�`8 7
Professions Code)
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Section CITY TEL NO
7044, Business and Professions Code)
OWNER
❑ 1, as owner of the property, am exclusively contracting Oumilt. Oaq A-4. IN
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) I ADDRESS
CONSTRUCTION LENDING AGENCY CIN TEL NO
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
CITY TEL NO
Lender's Address
STATE LIC
I certify that I have read this application and state that the LICENSE NO CLASS ^ O
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction,
and,hereby authorize representatives of this County to enter '
Up
t
a ve- enllone property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _ M
�— -5�
Signoture of Applicant or Agent Date