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VttU KLIts'CUAA1'ENSA'f)UN DECLARATION d CEA 818(2-80) A P P UC 6';AT 0®N FOR P E R� T
I hCrelby affirm that I have a certificate of consent to self III
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATINGI-, CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.) 'fl
Policy No. Company I
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county building inspectionI FOR APPLICANT TO FILL IN BUILDING
department. e2
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LOCALITY G
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NE�IREST
(This section need not be completed if the Work involved ABSORPTION UNIT, BTU CRSS ST. d
by the permit is for one hundred dollars (S100) or less.) DISTRICT NO. PROCESSED B O
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM IU/� Y I d".v - U
permit is issued, I shall not employ any person in any manner �,J V u
so as to become subject to the Workers'Compensation Laws. I BOILER,BTU O
Dat �� �a� ``rr ��• APPROVALSAVALIDA
INSPECTOR'SSI ATURE V
��Applicant c� r COMPRESSOR,BTU y� d�0 GS W
ROUGH IL
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM �
Exemptipn, you should become subject to the Workers' FINAL Z
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER fON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU ' RVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU A (J ��
I hereby affirm that 1 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. z t2L LiG20
License Numbe , c.Class
# aao ° ° g
ElI am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above. 9 - 3Q50
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$1 1019 )
ux
Lie.or Reg.No. Date TOTAL FEE ° ° ° 'J Q 5 0
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0 1.31 -85
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 TEL.NO.
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code).
❑ OWNER
I, as owner of the property, unt exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code).' j ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency CONTRACT
O 1
for the performance of the wort: for which this permit is CONG
issued (Sec.3097,Civ.C.).
Lender's Name ADDRESS 174,5,0
Lender's Address CITY TEL.N2Zr ,p y9
I certify that I have read this application and state that the STATE / LIC. v
above information is correct.I agree to comply with all County LICENSE NO �? Z CLASS G' Z a
ordinances and State laws regulating i-[eating. Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon. the above-mentioned property for
inspcctio pu pose
� C'
Signatu of Permittee Date
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