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' 11VORKERS'• I h6ve a cerci DECLARATION APPLICATION FOR PERMIT
I hereby �iff'rrm,that I have a certificate of consent to self
" .insure, 61 a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800;Lab. C.) I 76A364C
Po'cy NoFA1F o#I T /1"Lam' Glrl SCE-818(REV. 10/81)
. Company I/1/ .
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county buil Ing inspec- FOR APPLICANT TO FILL IN BUILDING 6'ID3
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date S_2 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE r
CERTIFICAT OF EXEMPTION FROM RS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. { PROCESSED BY
AIR HANDLING UNIT,CFM •
the permit is for one hundred dollars($100)or less.) /v'
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person-in any manner
so as to become subject to the Workers'Compensation Laws. . BOILER,BTU ,{ APPROVALS DATE INSPE 'S SIGNATURE
Date Applicant COMPRESSOR,BTU' (J QI� ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �'
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAY
LICENSED CONTRACTORS DECLARATION FLOOR BTU (f (J
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT i
'(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and m license is in full force and effect.
�^ y 2aS
License Number,S O �3 Lic. Class (2' —97 1 2 9 A / 11.7
Z_az09
Contractor Date — # 0 0 0 0 0 8 O
.I �,a4275 LU
I am exempt u ec. Plan check feeIL
B.&P.C. for this reason' o o a 427556 #A
Date:
PERMIT ISSUING FEE$ .S .0528-87
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 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). �j�,�
OWNER 1, MRN
❑ I, as owner of the property,am exclusively contracting
lif
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 13 Z. CT6&4)60,6
CONSTRUCTION LENDING AGENCY CITY ®��L TEL. NO.
I hereby affirm that there is a construction lending agency for 'e
the performance of the work for which this permit is issued CONTRACTOR 6 �Q/Ie��T�(�J(/�R�G ^�� •,
(Sec. 3097, Civ. C.).
ADDRESS 1SL� 6z*, S
Lender's Name a3
Lenders Address - CITY G ()) TEL. NO. 2-7
STATE �1� �G LIC.
I certify that I have. read this application and state that The LICENSE NO. J(/ CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby autho'ze representatives of this County to enter
upon the ab e- entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�,daf PoR.
Slgnafur Applican r Agent Date '