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WORT,LRS' 76A364C COMPLNSATION DCCLARA710N 76818 (2 80) APPLICATION FOR PERMIT
t Mrebt a6f7•rm that I have a certificate of consent to self
insdre or k certificate of Workers Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a cet•tifteQ,,copy thereof(Sec 3800 Lab C)
PolWy NJ WFatiSoiYipany��/Tr_�A��
11 Certified copv is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
�ertified copy is filed with the coFOR
unty h ilding inspection BUILDING
departmen APPLICANT TO FILL IN
Dateg! � Appltcant_ _
LOCALITY
(PRINT OR TYPE ONLY) ADDRESS
CERTIFICATE OC EXLMPTIO + FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE (?
COMPENSATION INSURANCE NEAREST r�X�-`=J }
(This section need not be completed if the work involved ABSORPTION UNIT BTU CROSS ST ti
by the permit is for one hundred dollars (5100) or less) DISTRICT NO PROC ED i V
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM r
permit is Issued I shall not employ anI person in any manner v 0
so as to become subject to the Workers Compensation La%%s BOILER BTU
APPROVALS DATE INSPECTOR S SIGNATURE
Date Applie,ant COMPRESSOR BTU ROUGH _ d
NOTICE TO APPLICANT If after making this Certificate of FINAL Z
VENTILATION SYSTEM
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
deemed revoked
FURNACE FAU GRAVITY
LICENSFD CONTRACTORS DECLARATION FLOGR BTU
i herebv 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 10,
effect �y
Alip
License Number�-7Sc Class
Contractor_ Date�-ZZ�'
El1 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) PERMIT ISSUING FEE$ 0
Lic or Reg No Date TOTAL FEE
HOME OWNLR BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's NAME w`�L! 0
yT
License Law for the following reason (Section 7031 5 Busi , N � ' 3307 12.25
nese and Professions Code) ADDRESS
1 ITEM
I, as owner of the proporty will do the work and the
structure is not intended or offered for sale (Section CITY f_ . r� ...TEL NO TOTAL 1 x.255
7044 Business and Professions Code) pCT'IAGY�aC CHEM
G �.
❑ OWNER ,�+ Y Pl�'�r�E CHEM
1, as owner of the property am exclusively contracting G.i
25
with licensed contractors construct the protect MAIL 00
(Section 7044 Business and Professions Code) ADDRESS rj �✓� f/w .
CONSTRUCTION LLNDING AGLNCY CITY to N G7�_npl TEL NO Z y '.�`pp
1 hereby affirm that there is a construction lending agency CONTRACTOR �C•711��L` tpR/1 ��Ll/07
for the performance of the %%ork for which this permit is
issued (Sec 3097 Civ C) +f 15G
Lender's Name ADDRESS 521 AM10:08
Lender's Address CITY TEL NO
I certify that i have read this application and state that the STATE
abo%e information is correct I agree to comply with all County LICENSE NO CLASS
ordinances and State laws regulating Heating Ventilating and
Air Conditioning and hereby authorize representatives of this SEE REVERSE COR EXPLANATORY LANGUAGE
County to enter upon th above mentioned property for
ti:; a ion pur
e of rmittee Date 2 F