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VYODXTRS�.COMPENSATION DECLARATION APPLICATION FOR PERMIT '
-•I f�rgb7caWm that I have a certificate of consent to self
'inf r!, or a eerhficate of Workers Compensdtion Insurance HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lab C ) 766_164Ct s
r CE B18(REV 10/81) - - --
Pal icy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county budding inspec- FOR APPLICANT TO FILL IN BUILDINGVk 5 C4"tLF_ C11 y 6L D.T6Lh0.E CGF
tion department (PRINT OR TYPE ONLY) ADDRESS
tm !1179-0
Date i Apphcont LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE f
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE �1J CROSS ST 49Lt✓�E St
(This stolon need not be completed M the work Involved by Y ABSORPTION UNIT BTU DISTRICT r PROCESSED ev
the Permit Is for ane J
hundred dollars ($100)or less) 4r
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM ( d
permit is issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation Laws A"MVAIS DATE JSWCTC0S 5JGNyURE
Date L� SY Applicant yam' U UA1Ac�
COMPRESSOR BTU ��r000 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 ID n N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEA ER SUSPENDED 'UNIT_
(commenting with,5echon 7000) of Division 3 of the Business WALL
and Professions Code and my license is in full farce and effect 6
License Number Lic Class - - , y
K
Contractor Date - OOF
❑ I am exempt under Sec - i W
Plan check fee d
B 8P C for this reason
Date Z
PERMIT ISSUING FEE $
-
Signature TOTAL FEE ;2969,5A
OWNER BUILDER DECLARATION RAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor s License 8
Law for the following reason (Section 7031 5 Business and NAME ( • • 3 Q 5 0
Professions Code) i
❑ I as ownei of the property or my employees with ADDRESS • • • 3 0.5 0 5
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) _ O OWNER 5 2 5-8'8
❑ Ias owner of the properly, am eruct the
contracting ,HAIL
with 044 Business
contractors to construct the prolecl (Sec . ADDRESSVD
tion 7044 Business and Professions Code) rem '
CONSTRUCTION LENDING AGENCY - CITY I C — TEL NO
I hereby affirm that there is a construction lending agency for 4,( Poo '
the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097, Gv C )
ADDRESS _ -
Lender s Name
CITY TEL NO _
Lender s Address
STATE LIC
I certify that I have recd this application and state that the LICENSE NO CLASS _ v
above information a correct I agree to comply with all County
ordinances and State laws relating to budding construction
and hereby authorize representatives of this County to enter r
6nn the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
0.,0 N 0�� led � a
Signowre of Applicant or Agent Dot -