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WOR KERS'COMPENSATION DECLARATION CEA 8618 C(2 80l Lla��i � ®II�I ®� PERWT
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1 hereby affirm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
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a certified copy thereof(Sec.3800,Lab.C.)
Policy No. 'Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES / / ' BUILDING AND SAFETY
0 Certified copy is filed with the county building inspection APPLICANT TO FILL IBUILDING
department. FOR IN
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' — — - - -
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT, 8TU CROSS ST `j. tl
by the permit is for one hundred dollars ($100) or less.) -� - - — DISTRICT NO PROCESS By V
1 certify that in theerformance of the work for which this AIR HANDLING UNIT,CFM
P cc
permit is issued, I shall not employ any person in any manner O
•n as to become subject to the Workers'Compensation Laws. BOILER, BTU V
Irca �� r -�� APPROVALS DATE INSPECTOR'S SIGNATURE I)
1)atfY3 ' pP COMPRESSOR,BTU ROUGH _ ` (� • +-- -� CL
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NOTICE TO APPLI ANT: If, er making this Certificate o� VENTILATION SYSTEM .-. • z
t vemption, you Should become subject to the Workers' FINAL
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 R VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT �(Z
9 (commencing with Section 1,000) of Division 3 of the Busi- WALL e�
ness and Professions Code,and my license is in fall force and
effect.
License Number PZZZ:25 Lic.Class- e- r,-2 06
Contractorl;3 % m:el1 ate _r--,/
13 1 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 $ '7
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
I, as owner of the property, will do the work and the CITY TEL.NO,
structure is not intended or offered for sale (Section
7044, Business and Professions Code). G
OWNER l 0 P_ 1•
I, as owner of the property, am exclusively contracting �! C_�IL1✓ G���_f_G
with licensed contractors to construct the project MAIL
0 0 0 0 0
(Section 7044, Business and Professions Code). ADDRESS lY
CONSTRUCTION LENDING AGENCY CITY✓ �`_ TEL.NO 2 0 0 `� ] 'J�;
I hereby affirm that there is a construction lending agency O G O ,n S
for the performance of the work for which this permit is CONTRACTORf����� r c:
issued(Sec.3097,Civ.C.). 0 1 19-81
Lender's Name ADDRESS �
Lender's Address CITY TEL.NO.
I certify that I have read this application and state that the TE
above information is correct.I agree to comply with all County LICENSE NO. +� Cl ASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorise representatives of this SITE REVERSE FOR EXPLANATORY LAN(,I;AGI•
County to enter upon the above-mentioned property for
inspectio purposes.
ie re of Permittee Date