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WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
'I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified cop thereof(Sec. 3800, Lab. C.) 76A364C
W, -) 3 9 C� CE-818(REV. 10/81)
Policy o. 9 Company � � 1%-�
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING �/
tion department. (PRINT OR TYPE ONLY) ADDRESS p{o�
Date I - S Y7 Applicant A_ 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. P SSE
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. /r APPROVALS DATE I SPE T R SIGNATURE
Date Applicant COMPRESSOR,BTU T?C / ROUGH Z /'
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE:. FAU )41TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU %«
JA
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. L_qA`
�l�i%�fc;l Lic. Class ~
License Number J , �
Contracto i ''i L`_Date ( ' -! 7 6'2 7,7 A O
0 0 0 0 0 8 V
F-111am exempt und(r Sec. 9L
Plan check fee I o o48.00 to
B.BP.C. for this reason Date: PERMIT ISSUING FEE$ 0 0 0 [; 8,0 0 TOTAL FEE 3
' Signature, 01.05-870 1,0 5 8 7
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 CITY TEL. NO.
the structure is not intended or offered for sale(Section
•
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING.AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR I U
(Sec. 3097, Civ. C.). Poo
ADDRESS , t�S
Lender's Name -
CITY
c- TEL. NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the [LICENSE NO. ?��(,�( ,1, CLASS V
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and reby authorize representatives of this County to enter
ul o a above-vientiongd property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date