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WORKERS,COMPEA-13ATION DECLARATION I APPLICATION FOR PERMIT
Aisureboraa certificate ofaWorkers'f ificate of consent to f
Compensation Insurance
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364c HEATING - VENTILATING - AIR CONDITIONING
RNA n CE-818(REV. 10/81)
Policy No.CD, Compariya 7Y1-dL
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS V V
Date ApplicantLOCALITY c� C;
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) Q
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 0
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE IN PE5TOR'S SIGNATUR
Date Applicant COMPRESSOR,BTU 0 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions-of the Labor Code, you must forth- EVAPORATIVE COOLER VAI InAfIdN
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY O
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full forced effect. CL
L '" License Number ���r Lic. Class8 4 8 A V
1 , 19
Contractor C_ Date I # a o 0 0 0 8
❑ I am exempt under Sec. w
Plan check fee I a 03 (150'
H
B.&P.C. for this reason'
Date: PERMIT ISSUING FEE$ 00 - 30,5050
•
Signature J TOTAL FEE �()
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 11,30-87
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
El 1,
I, as owner of the property,am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
ADDRESS t �rLr�
tion 7044, Business and Professions Code).
+ CONSTRUCTION LENDING AGENCY CITYc �°- TEL. NO. ����
I hereby affirm that there is a construction lending agency for - ;
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
rdina6ces and Simte laws relating to building construction,
nd hereby auth ri a representatives of this County to enter
upon the ve- ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date