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WOR'kL'RS'CO*iPENSATI6N DECLARATION CEA S B (2-80)
.h1 I�lid p �C AT�®1 11 FOR
R P E R F�,CI T
1 hergby affirmr� that I-have,,a• certificate of consent to self 6�Ir Ir Ilv �I I� if S ff tf`6 9�YU
insuroa'or a ce%fica,W of Work'ers'Compensation Insurance,or
a certified copy thereof(Sec.3$00, b. .)
Policy No.W / I-IE�►TIIVG'V�V�ITILAYIi11Ca-A16d COPT®ITI®iVII6�G?
dI6 S2` anY
54 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
F1 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
de ar t•
Date 1 �
Applicant � (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' . NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEARESTJIVY
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. d
by the permit is for one hundred dollars (S100) or less.) DISTRICT NO. PROCES ED v U
I 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 0
so as to become subject to the Workers' Compensation Laws.- BOILER, BTU
APPROVALS DAT INSP S SIGN13
A URE
Date Applicant I COMPRESSOR,BTU ROUGH IL
LU
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should .become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit'shall be
deemed revoked. FURNACE: FAU IT
LICENSED CONTRACTORS DECLARATION_ FLOORd BTU
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 NumberLic.Class
Contractor Date
I 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 Q Al2 6 A
Lic,or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK,APPLICANT # o 0 o'e,0 8
I hereby affirm that I am exempt from-the Contractor's (NAMEY
License Law for the following reason (Section 7031.5, Busi- Vo:0 41 0 0
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and theTEL.NO. o,0 0 4 8 0 0 U
structure is not intended,or offered for sale (Section CITY _
7044,Business and Professions Code). 1 O 2 OWNER 0 G $7
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS .d
CONSTRUCTION LENDING AGENCY CITY 1TEL.NO.
,
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued(Sec.3097,Civ.C.).
Lend'er's Name ADDRESS AlL. All
Lender's Address CITY TEL.NO. _61
I certify that I have read this'application and state that the STATE LIC.
above information is correct.1 agree to comply with all County LICENSE NO. 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
V4A
n purposes. -
i/T/ �
e of,P i{tee Date
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