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WORKERS'CUMPENSATION DECLARATIOL4 e I CEA 8Pii:(2-80) LL,0�6=a�0®II�I ®� LS ��
I htirehy I afllrm that I have a' certificate of conse0't'to self
insure, or a certificate of Workers'Compensation Insurance,or p�EATppvG_bEN'1•IL�►TIW�,-Alla ®fivDpTlOiVlppb�i
a certified copy thereof(Sec.3800,Lab.C.) �•
Policy N.40-0732Company _C33toap
Certified copy is hereby furnished. •
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspection BUILDING
departmentADDRESS
��. _ _ FOR APPLICANT TO FILL IN -
Date _toa�cp
LOCALIT
CERTIFICATE dF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need not be completed. if the work involved ABSORPTION UNIT, BTU CROSS ST. d
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY 0
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner cc
so as to become subject to the Workers'Compensation Laws. BOILER, BTU 0
APPROVALS DATE INSPECTOR'S SIGNATURE (—
Date Applicant } COMPRESSOR,BTU .-�� .J AY a
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEMFINAL m c s'7 - %n— Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be VALIDATION
deemed revoked. FURNACE: FAU RAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU .1
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number�__!� �Q Lic.Class- (J/
Con racto 41"_ Date
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). { PERMIT ISSUING FEE$
Lic.or Reg.No. Date I TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's I NAM G 8 Ll 6 %A
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): I ADD RESS + o 0 0 0 o 81, as owner of the property, will do the work and the CIT TEL.NO �SaZ�
structure is not intended or offered for sale Section l o - 30.50
7044,Business and Professions Code).
❑ OWNER
I, as owner of the property, am exclusively contracting I u o 0 3 0.5 C"c,
with licensed contractors to construct the project I MAIL
(Section 7044,Business and Professions Code). ADDRESS S 1220-82
CONSTRUCTION LENDING AGENCY CIT r TEL.NO.
I hereby aftirin that there is a construction lending agency I
CONTRACTOR` G
for the performance of the work for which this permit is l
issued tSec. 3097,Civ.C.).
Lender s Name ADDRESS 7
Lender's Address CIT TEL.NOa�r��Z
I certify that I have read this application and state that the STATELIC. /� Z
above information is correct.I agree to comply with all County I LICENSE NO. r Q CLASS `.>^
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
ins ection purp tes.
. t<, I aL- I �-
Signature of Permittee Date