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W lI ERS CI have cerciTION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self ,
Insure or a certificate of Workers Compensation Insurance l HEATING VENTILATING AIR CONDITIONING
or a certifiJ14 copy thereof(Sec 3800 Lab C ) 76A364C
`/ ,,— t ! CE 818(REV 10/81)
Policy No 73?~ Company rrR/I/J-/J, 1'
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec I FOR APPLICANT TO FILL IN BUILDING ,EZ—r_
tionpart e f ADDRESS J
l/ S r /�� (PRINT OR TYPE ONLY)
Date C? Applicantg LOCALITY
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 PROCE D BV
the permit is for one hundred dollars($100)or less) 4
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM to O
permit is issued I shall not employ any person In any manner BOILER BTU
so as to become subject to the Workers Compensation Laws APPROVALS DATE IN PECTOR S SIGNATURE
Date Applicant COMPRESSOR BTU ROUGH
it
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 GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED NIT �)
(commencing with Section 7000) of Division 3 of the Business WALL lU
and Professions Code and my license is in full force and effect }
_ 9 d
License Number �•� Ic Class V
Contractor ��f� /�(r Date (( I , 09O
t—
❑ I am exempt under Sec
Plan check fee
IA
B&P C for this reason PERMIT ISSUING FEES Y
Date
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT�IOe/VX
I hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and NAME 7A'7/J7�
Professions Code) i
❑ I as owner of the property or my employees with ADDRESS e �r
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section I CITY ,a T9 NO �7�
7044 Business and Professions Code)
OWNER i
Elas owner of the property am exclusively contracting 1 W_- lY7
with licensed contractors to construct the project (Sec MAIL
�7: $ Q 7
tion 7044 Business and Professions Code) ADDRESS .. #Tr 5 1d M 1 g
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there Is a construction lending agency for I o * 2050
the performance of the work for which this permit is IssuedCONTRACTOR 2 Q 5 Q=
(Sec 3097 Civ C ) -
ADDRESS 105-86
Lender s Name
CITY TEL NO gL' _ _
Lender s Address
STATE LIC
j 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
ordin nces and Stat s relating to building construction
n ereby horiz a esentatives of this County to enter
u v Ito r or Inspectto purp ses SEE REVERSE FOR EXPLANATORY LANGUAGE
� r s- �
Signature of Applicant or Agent Date