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WORKERS•�oMPENSAT�oNOE«ARAT�oN � APPLICATION FOR PERMIT � � �
I hereby afFkm that�I have a certificate of conseM lo self
Insu�,or o�{rtifimte of Workeri Compensotion Insuronce,. - - . . .
or o��ertified copy ihereof(Sec.3800,Lob.C.) ienaa<c . HEATING�- VENTILATING • AIR CONDITIONING
1 CE-81e(REV.10/BI) -
Polity No. ' Compony�-��, - � .
Certifed mpy is hereby furnished. COUNTY OF LOS ANGELES . BUILDING AND SAFETY
Certilied copy�s filed with the county build�ng inspec- FOR APPLICANT TO FILL IN Bui�oWG //
tion deparlm n � ADORESS � � � �J/.
(PRINT OR TVPE ONIY)
Dafe�_Applicanl � — IOCAUTV -� .
NO. TYPE OF APPLIANCE OR EOUIFMENT FEE
� CERTIFICATE OF ExEMPTION F O WORKERS' NeaeESt _ .
COMPENSATION IN RA CE � Crt055 5T. - " " .
(Thts�eellen naad nof be eomplafad i fhe work Involved by ABSORPTION UNIT,BTU DiSTRlC7 NO. PRp�E55ED BY
}he parmN is for one hundred dollars(SI00)or less.) .
�I certily thm in�he performante of the work for which this A�R HANDLING UNIT,CFM U .
permit is fss�ed,I shall not employ ony person in any manner gOIIER,eTll ',,1 -
- so as to become subject to the Workers'Compensation Lows. � V V APFROVAlS DAiE I .G C 0'S SIGNATIIRE
DC1e APPlicont � CaMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT:�If, afier making this CertiFicate of VENTRATION SYSTEM FINAL -
E�emption, yo� should become subject to the Workeri _
Compensation provis�ons of the labor Code,y0u mu2�IOrt11- EVAPORATIVE COOLER VALIDATION
� with mmply with tvth provisions or this permit sholl be
deemed revoked. ' � FURNACE: FAU_GRAVITY �
� . LICENSED CONTRACTORS DECLARATION FLOOR BTV � � ,
I hereby affirm thm I om licensed under provisions of Chaprer 9 HFATER: SUSVENDED UNIT_ � . ' � �
'(tommencing with Sectlon 7000)of Divislon 3 of the Business ' wA�� '
ond Professions Code,and my license is in full force ond effecr. � � � ---- - .. ' y ,
_ License Number �I�i O f Q Lia Class��� . � � ► � . V
r �(� �����/� oC
ConhoUor`�OG.-d Date___4._��� r - � . . . �
f-
❑ I am exemp�under Sec. _ . _ _ . . . ' a
Plan theck fee .
B.&P.C.for this reoson� . � .. y
PERMIT ISSUING FEE S /0 .Sv � z
Dote: TOTAL FEE c�ld Z} !
$ignafure � -
� OWNER-BUILDER DECLARATION FLAN CHECK APPIICANT �' � � �
\ I hereb�;��f(irm thot I am ezempl from the Conlrador's License
Law fo� ie following reason(Section 7031.5, 8usiness and NnME � �- � - ' � �� J Q 2 A
\Profr' � s Code�: � - - - ,
� ADDRE55 � o �
,s owner of the property, or my employees wi�h '�— . �� � � �$
ges as fheir sole mmpensation,will do the work and UTY ' ,.� TEL NO. - ��
�structure is not intended or offered�(or sole(SeUion � ^ Q J��
f4,Bosiness ond Professions Code�. � - - -
OWNFR. � � S
os owner of 1he prope�ty,am excl�sively confrocting a '3 0.5 0 c�
e�i licensed tonhacrors�o constroct the piojett(Sec- MAa � - q
m 7044,Bosiness and Professions Cade). A�DRE55 � 0 �2"8 7 �
`CONSTRUCTION LENDING AGENCY Citv � � � -� TEI.td0. � - �� � �� . � �
r affirm that Ihere is a mnstruction lending agency(or ' "
formance\of the work for which this permi�is issued [ONTRAQ �,ti w{- . - � - , � -
J97.Civ.C.� � ' � --� -- . �
. \ ADORE55� � C �. -. . . - �- ' ..
's Name � (�
� � CIN Q�� /r - .TEL.NO.5S I��a' _ � � . . , .. ..
�r's Address '� '�
� 57ATE (� LIC. �
tify thal I have read ti�is opplimtion and s�ate ihat rhe LICENSE NO. . �-` � � . - ttA55 �.�.a-��� ���������� �- � � �.. � ` . �
�e informaiion Is corred.I agree to comply with oll County . . _ - ' " ,
inances and 51ate lows relating fo bUilding construction. � � _ � -
!hereby authorize represenlatives of this Counfy 10 enter - � � .
on the above-menlioned propeity(or in�edion pu�poses SEE REVERSE FOR EXPLANATORY LANGUAGE
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