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„�WORKERf' I Ka%itNa cerci cafeDECof corse APPLICATION FOR PERMIT
I,�reb'.y afjitlrt'tb'at'I fiaJe a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified cd�y thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
I
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING l{ j r
tion department. G
. (PRINT OR TYPE ONLY) 6
ADDRESS
Date Applicant LOCALITY C
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE I 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 (f
permit is issued, I shall not employ any person-in any manner BOILERBTU
so as to ,become subject to the Workers'Compensation Laws. APPROVALS DATE INSP R'S SIGNA URE
Date pplicant f COMPRESSOR, BTU ROUGH
NOTIC O A LI&KNT: If, after making this ertifi to of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
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 9SUSPENDED;,,----UNIT—
'(commencing
USPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
License Number- Lic. Class , V
Contractor Date z 7 9 8'A
❑ V
I am exempt under Sec. � o 0 0 0 o W
Plan check fee # 8 y
BAP.C. for this reason' PERMIT ISSUING FEE U 5 1'- - 21150 d
- Date:
TOTAL FEE 0 0 0 2 0 5,0 v
Signature i '
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 09.22 8 7
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME ,
P%rofpsas Code): 14
1
I, 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). c—
S� ��.
❑ I, as owner of the property, am exclusiveOWNER ly contracting MAIL '
7 .
with licensed contractors to construct the project (Sec- ADDRESS Q
tion 7044, Business and.Professions Code).
CONSTRUCTION LENDING AGENCY CITY ` EL.'NO: ® 's
I hereby affirm that there is a construction lending agency for. oil.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 V LIC. '
I certify that I have read this application and state that the LICENSE NO. ly CLASS
above information is correct. I agree to comply with all County.
ordinances and State laws relating to building construction,
and.h9Fe-ByVuthorize representatives of-this County to enter,-
u n t a ve-mentionedro . rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant.or Agent Dote