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WORKERS COMPENSATION DL'CLARIA!iD- CEA 818 (280) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure or a certificate of Workers'Compensation Insurance or ,HEATING-VENTILATING-AIR CONDITIONING
u certified cop) thereof(Sec 3800, Lab C) ,
Policy No�{�jo-9}Company—S7A�tcuAUp
Certified copv Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
F1 Certified copy Is filed with the count) budding Inspection FOR APPLICANT TO FILL IN 1t BUILDING
dcpanmi-tit l ADDRESS
Date Applicant Applicant _ _ _ (PRINT OR TYPE ONLY) f
--_� ' LOCALITY /
CERTIFICATE OI'EXEMPTION CRO'.WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE '
' COMPENSATION INSURANCE I NEARESTn-
(This section need not be completed If the work mvotved ABSORPTION UNIT BTU CROSS ST
by the permit is for one hundred dollars ($100) or less) - , DISTRICT No PROCESSED n O
1 cenlfy that In the performance of the work for which this AIR HANDLING UNIT CFM- i 1((((J�
permit is issued I shall not employ any person in any manner _ s cc
so as to become subject to the Workers Compensation Laws BOILER BTU , 0
�r APPROVALS DATE INSPECT SSIGNATURE 'U
Date Applicant / COMPRESSOR BTU_IiROUGH �A 'L _ d
1—
NOTICE TO APPLICANT If after making this Certificate of - VENTILATION SYSTEM _VL.�Sv� U)
Exemption you should become subject to the Workers FINAL 2
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_
LICENSED CONTRACTORS DECLARATION FLOOR BTU
—
I herebv affirm that I am hcensed under provisions of Chapter HEATER SUSPENDED UNIT ^
9 (commencing with Section 7000) of Dmsion 3 of the Buss WALL ,
ness Ind ProfessionsCodeand my license is In full force and
effect
Lt,ense Number Lic Cla,s C —7D
Contractor
1 am exe�m/pr reom the licensing requirements as I am a
licensed architect or a registered professional engineer Plen check fee 25%Of BbOve
acting in my professional capacity (Section 7051, Bus /O O
mess and Professions Code) PERMIT ISSUING FEE $ '
Lic or Reg No Date TOTAL FEE
HOME OWNER BUILDER'DECLARATION PLAN CHECK APPLICANT
t
I hereby affirm that 1 am exempt from the Contractor's NAME Mao p✓�J - o
License Law for the following reason (Section 7031 5 Bina i, •_ - • — V
nus and Professions Code) ADDRESS �2. ACCa
I,-as owner of the- ro art will do the work and the , rT•~
P P Y, b,d/f.L
structure is not Intended or offered for sale (Section CITY / P� C'N� TEL NO 3M7 ti�sc 34•e5l '
7044 Buwnessand Professions Codef / 1 I1G t0
OWNER
I, as owner of the property am exclusively contrActing �M-/V VN-GJ L
with licensed contractors to construct the PrOjeLt MAIL i '�'�� _ 34 �'��
(Section 7044, Business and Profession,Code) ADDRESS 07&� /L j Z ..e ' -
CONSTRUCTION LENDING AGENCY CITY / TEL NO �76 g-,a�f-L r CHECK .34.50
I hereby affirm
that there is a construction lending agency 7 +'_'tGL1- ~
for the performance of the work for which this Parisi[ is CONTRACT6R �G
issued (Sec 3097,Cry C)
Lender's Name ADDRESS 9Z0 �\ /AS 7U�A�uR ;,
Lender s Address / " TEL
00W"'�1 8� '� r
CITY -r�,' TEL NO / Q42 I AM10:01
I certify that I have read this application and wale,that the 127'f YOTL
STATE LIC
.above information Is correct I agree to cumpl) with all Count) LICENSE NO 1.� CLASS C '
,rdmances and State laws regulating Heating Ventilating and
lir Conditioning and hereby authorise representatives of this SEE REVERSE COR EXPLANATORY LANGUAGE
runty to renter upon the above mentioned property for
speomn r •-s
;notate , Yer i
i •