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0653A (8)
• WORKERS'COMPENSATIONDECLARATION APPLICATION FOR PGRMIT � I hereby affi+m tha� I hove a certificore of tonsent to self in:ure,or a certiFlcaie of Workers'Compensaron�nsuro�ce, �6A36ac HEATING - VENTILATING - AIR CONDIiIONING or a tertified copy Ihereof(Sec.3800,lab.C.) CE-818(REV.10/81� -<', � PoGcy No.l�'i I`-; " �7 Company ��..r I t ���� . f:: Q fCe�rified mpy is hereby uf lihed:. ;"'/� • , COUNTY OF LOS ANGELES BUIIDING AND$AFETY O Certified copy is filed�h the toomy building-Y speo- FOR APPIICANT TO FILL IN BUILDING ��-. �� � f ,-" tion deparlment. / � / i . . �PRI M O R TY P E O N L Y) ADORE55 � F:� L�� � � �.���: � � �Do�e � `� �; APPlico '�•.r� ..I��%i LOCAUTY ? � . � NO. TYPE OF APPLIANCE OR EQU�PMENT FEE. '�� CERTIFICATE OF EXEMPTION FROM�WORKERS'� NEnRESi -� COMPENSATION INSURANCE Ce055 ST. ..i;: r '•� � (This saction naed not 6a complvled if fhe work involved by AB$ORPTI�N�1NIT,BTU DIS�RiCI NO. GROCESSED BV � tha permil is for one hundred dollars�f100�Or�e�s.� qIR HANDIING UNIT,CFM - I cerfify thot in Ihe performonre of ihe work for which this , � � � permif is issued,I shall not employ any person in any monner BOILER,BTU so os lo become subjeU to the Workers'Compensation Lows. avvzovn�5 oar[ � � INSiECTOR'S SIGNAiURE � Dale ,Appli[ont . COMPRESSOR,BTV ROUGH NOTICE TO APPLICANT: If, afier making lhis Cerlificate of VENTRATION Sv57EM FINAL ' EMemption, you should 6emme subject to the Workers' , Compenso7ion provizions of Ihe Lobor Code,you must forih� EVAPORATIVE COOLER VALIDA?ION wi�h comply with such provisions ar Ihis permit shall be �deemed revoked. FURNACE: FAU__GRAVITY � � LICENSED CONTRACTORS DECLARATION FLOOR BiU I hereby affirm that I am licensed under provisions af Choprer 9 HEATER: SUSPENDE� uNii_ } '(commencing with Setlion 7000)of Division 3 of the Business WA« p. and Professions Code,ond my license is in full force and etfect. Q , �i .,-'J"; -y � � ! V - l(cense Number �' Lia Class �- - � , W � .I LL CoNroctor� � � ' Date�_ y ❑ �' � ' � I am exempi under Sec 1 r a� -��:"r"a Q Plancheckfee ,�f'.��•f'� � , 6.8P�C.for this reason- �! . � •, .�.`�,i�. � O i i PERMIT ISSUING FEE S j�;!;�„;+,�,�. °� � � Da�e: .. ..� \ ' � TOTAL FEE 'rl'�"r ' i;' '+' SignaN(e -�'r��' � �/ - - . �i�+'r�1: 1 �' . OWNER•BUILDER DECLARATION �'� CLAN CHECK APPIICANT '�t�''�:�:�f,'N ' I hereby affirm ihat l am exempt from the Conlroclor's License , , � - ' ''���"'''��'���' Low for Ihe followin reason Secfion 7031.5, Business and NAME• 'j " ;,/ !, �' r Professions Code): 9 ( � J� ``'�'�"'C`'"�'F�� ❑ I, os owner of ihe property, Or my�employees with ADORESS l j� i�.-� �. '� � j �,�� � wages as their sole compensalion,will do ihe work and Citv ' ' ,7EL.�NO.� the structure is nol in�ended or offered ior sale(Section �-'1 .. _�,���' ' � - � , � • 7044,Business and Professions Code). ' OWNER , �. .. � . ❑ I,as owne�of the propeny,am ecclusively mNrocfing with litented contractors ro tonstruct ihe projeU(Seo MA�� , , i ' � fion 7044,Bosiness and Pro(essions Code). ADDRE55 ' _ . CONSTRUCTION LENDING AGENCY Ci7V ; �!,� . . TEL NO. ; �.�. .'� � I hereby affirm ihot Ihere is a conslruUion lending ogenty for � ' ► Ihe performance o1 Ihe wo�k�for which Ihis permit is issued �ONTRACTOR _!� , �,� � " . (Sec 3097,Civ,C.). � ' ADDRESS� •� � :'t . � Lender's Nome ' ' �� � CITY ,� TFL�.f`�O� �''j,:,i - � } lender'�A:ddress �--� ' - � . STATE ���� " � UC. I cerli(y fhot I hove read Ihis pplimlion pnd stale that the UCENSE NO. ! '�•1� I .1 � ' �CLA55 � , above infqrmation ii mrrect.�gree b mmply with oll Couniy ordinon�es and State laws•relo�ing to building wnstrucfian, and.heieby authorize represen�atives of Ihis Cooniy 7o enter . � . � upon,flle'above-meniioned pr perry for inspection purposes. 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