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WORKI RS'COMPLNSATION DFCLARPTION 76A364C
I hereby affirm that I hese a certificate of cement to self CE 81a (280) APPLICATION FOR PERMIT
Insure or a certificate of Workers Compensation Insurance or I '
a certified copy thereof(See 3800 Lab C) HEATING-VENTILATING-AIR CONDITIONING
Policy No Company
❑ Certified copy is hereby furnished - _ COUNTY OF LOS ANGES BUILDING AND SAFETY
❑ Certified copy is filed with the county budding inspection
department FOR APPLICANT TO FILL IN BUILDING
pate Applicant (PRINT OR TYPE ONLY) ADDRESS 1
CFRTIf ICATE OF EXEMPTION FROM WORKLRS LOCALITY ��'
NO TYPE OF gPPLIAN CE OR EQUIPMENT FEE
- COMPLNSATION INSURANCE _ NEAREST _ y
(This Section need not be-completed if the work Involved- ABSORPTION UNIT BTU - _ CROSS ST kaRosa iL
by the per nut is for one hundred dollars ($100) or less) - DISTRICT NO PROCESSED BY
I certify that in the performance of the work for which this AIR HANDLING UNIT m CFM—
permit /
permit is Issued 1 shell not employ any person any manner _ O
so as to become subject to the Workers Compensation Laws BOILER BTU
APPROVALS DATE, INSPECTOR SSIGNATURE 6 U
UateAe4:41 Appbcnni �d COMPRESSOR BTU_4_a�00.4 _ ��� y
ROUGH
NOTICE TO APPLICANT If al r making this CunOcate of VENTILATION SYSTEM / Z
Lxempnon you should become subject to the Workers FINAL
Compensation prosisions of the Labor Codi, you must forth EVAPORATIVE COOLER
with comply with such provisions or this permit shall be VALIDATION
deemed re,oked FURNACE FAU.6— GRAVITY
LICENSI DCONTRACTORS DECLARATION FLOOR
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busl WALL
ness and Professmns Code and my license is in full force and
effect
License NummbQber-6_3�3
0 /Lit Classs--! �as.C�
Conlmctorj��lf/A�6dr,(�(rete_�(/JO�S�
❑ I im exempt from the
licensing requirements as I am a
licensed architect or a registered professmna) 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 TOTAL FEE
HOME OWNLR BUILDER DECLARATION PLAN CHECK APPLICANT `-
1 herby affum that 1 am exempt from the Contractors NAME
License Law for th, following reason (Section 7031 5 Bust
nes,and Professions Code) ADDRESS _
❑ I as owner of the property will do the work and the
structure is'not intended or offered for sale (Section CITY TEL NO ;94024A
7044 Business and Professions Code)
OWNER /�� /x We'*1* 41
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044 Business and Professions Codc) AD DRESS.T&I SLA) .2,-'- 3 7 0 0
CITY ��rro.. .__isJe /''. � EL NO.;? _ •I� 3700'6
CONSTRUCTION LENDING AGENCY / /�./J�./ `- e(P� I
I hereby affirm that thLre is a construction lending agency )
for the performance of the work for which this pr.rm[t is CONTRACTOR Geha�C ( - 02,10-81 -
issued (Sec 3097 Civ C) W7 —/T rVK—. -
LendersName ADDRESS,(a_'f0
Lender s Address -
CITY
C_�—/+Q�rJ� TEL NOC;g� _
1 certdv thSTA
III,( 1 have read this application and state that the SWT CO W��JO
TE LIC
abuse information is correct 1 agree to comp] with all County LICENSE NO 330 CLASS
ordinances and State laws regulating Hcatinb Ventilating and
Air Conditioning and hereby authorize represematnes of this _ SLL RLVLRSE I OR EXPLANATORS 1 ANGUAGE
County to enter upontheabuse mentioned pproppeerrtty/ for
u- cation PGhJ.iG�—W
Sig ore of Permittee Date ♦