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i ' WORKERS'COMPENSATION DECLARATION CEA'818(2.601 6=a I�����D®I�1 ®� u�ll u
I hereby affirm that I have a' certificate of consent to self, `I I
insure,or a certificate of Workers'Compensation Insurance,or; HEATING-VENTILATING-AIR CONDITIONING U
a certified copy thereof(Sec.3800,Lab..C.) I
Policy Compan
Certified copy is hereby furnished.y COUNTY OF LOS ANGELES BUILDING AND SAFETY `
❑ Certified copy is filed with the county building inspection FOR APPLICANT'TO FILL IN BUILDING . /s?
department. ADDRESS
Date Applicant 1 (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE • i NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. CL
by the permit is for one hundred dollars ($100)•or less.) DISTRICT NO. PROCESSED 9Y — U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ��QO�/ cc
permit is issued, I shall not employ any person in any manner O
I-Was to-become subject to the Wo ers'Co ion Laws. BOILER,BTU'
ooAPPROVALS - DATE INSPECTOR'S SIGNATURE W
Date/!*, )"Applicant COMPRESSOR,BTU QQ�after ROUGH r CO)
�7 '�"
NOTICE TO APPLICANT: If, aer maki th Certificate of VENTILATION SYSTEM FINAL G� 8( ` Q"�t Z
Exemption, you should become subject to the Workers' I
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: FAU041 GRAVITY ,
LICENSED CONTRACTORS DECLARATION FLOOR: BTU Q '
I.hereby affirm that I am licensed under provisions of Chapter's HEATER: SUSPENDED. UNIT
9 ('commencing with Section 7000)of Division 3 of the Busi- WALL
ngss and Professions Code, and my license.is in full force and
elect. 36�'''����
License Numbers Lic.Class r d
Contractor to
I
lam axe t from the I -ensing 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).
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the TEL.NO.
structure is not intended or offered for sale (Section CITY
7044,Business and Professions Code).
❑ OWNER • I 7_3 0 7.2 A
I, as owner of the property, am exclusively contracting 00/ id
with licensed contractors to construct the , project MAIL # 0 0 0 0 4 1
(Section 7044,Business and.Professions Code). l ADDRESS
CONSTRUCTION LENDING AGENCY t' CITY TE.L.NO. ,2o o87.00
I hereby affirm that there is a construction lending agency ` (.
for the performance of the work for which this permit is CONTR , a�ACTOR i�Y C f/V o a 0 87005
issued(Sec.3097,Civ.C.).
Lender.s Name ADDRESS $ i 1. 14-80
Lender's Address CITY TEL.NO.
I certify that I•have read this application.and state that theSTATE r LIC.
above information is correct.I agree to comply with all County +. LICENSECLASS '
ordinances and State laws regulating Heating,Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ante up e'above-mentioned property for
i1 a 'on purp es.
. f `��
Signature of Per t Date