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i � WORKERS'COMPENSRTION DECIARATION � I hereby affKm that I have a certifimte af�o�5e��fo,e�f APPLICATION FOR PERMIT insure,ono.certifimta of Workers'Compenso�ion�nwrance, -HEATING - VENTILATING - AIR CONDITIONING �cr qce�tified'copy fhereof(Sec.3800,�L�j b.C.) �6A364� _ _ . . ,_ . _ , (U�L.3 'l7 ("QCL�tC �a�+'n^wCee.aie(aev.ioiai� ��olic No.�Company ' - Certified copy is here6y furnished. COUNTY OF LOS ANGELE$ - BUILDING AND SAFETY ❑ Certified copy is filed with the munty building I speo- FOR APPLICANT TO FILL IN qooeess.2��� Orli a"�Ce.IC �� lion part enf. //]] � / (PRINT OR ttPF ONLY) .-� r q � �2. Q^iT lOCnt�iv /Q Da1e PPa�V � � M�d � N0. TYPE OF APPIIANCE OR EQUIPMENT � FEE I��� CERTIFICATE OF EXEMPTION FROM WORKERY . - NEAREST � COMPENSATION INSURANCE . Crtau 5T• (Thts sodion noad not be complefed it ihe work involved by ABSORPTION UNIT,BTU DISiR�CT NO. PRpCFSSED 8Y the permit is for one huedred dollors(SlOo)or Iess.) , I ceNify fhot fn Ihe performance�oi the work for whith this A�R HANDLINfi UNIT,CFM ,O _. C C>'V�_7 perml�is issued,I shall not employ any person in any monner gpILER,BTU — so as to become subjed to the Wo�kers'Compensa�ion Laws.. AvvaoValS DA7E INSPECTOR'S SiGN�tURE Da1e � Appliconf � COMPRESSOR,BN ROVGH - ,., - NOTICE TO APPLICANT: If, afler moking this Certifimte oF � VENTItATiON SYSTEM FINAL -� - � Eaemption, yo� should become wbject to�the Workers' �Compensotion provisions of the Lobor Code,you must forth- EVAPORATIVE COOLER VALIDATION wilh mmply witb such provisions or this permit shall be . � �deemed revoked. � � . � FURNACE fP.U_GRAVIN ��� � LICENSED CONTRACTORS DECLARATION . FLOOR BTU I hereby affirm that I am Itcensed ander provislons of Chopter 9 NEATER: SUSPENDED UNIT_ - ."(commencing wi�h Sedion 7000)of Division 3 of Ihe Business ' WA« � and Professions Code,and my litense is in ful I force and effecL .♦ �- ��� � � . . p�. e2/.L�o9L �'.L� ` � ' License Number Lic.Class - . � -� - ► , V [y� /'�/ OG � . Contrac��'^M"`Q�� Date . . . .. . _1j� V . � � I em ezempl under Sea � . . . . . _ . wY W � Plan check fee �l� a � N B.&P.C.for this reoson pERM1T ISSUING FEE S �� (L z Dore: TOTAL FEE � �\" Signatura OWNER-BUILDER DECLARATION MP,N CHECK APPLIUNi � ` j--�,� . \ p � I hereby o!lirm lhat I am exempt from Ihe Controdor's ticense - - � . � law for ihe following reason(Section 7031.5,Bosiness and NAME r J-f'r7jyt- � � C n J r -- Professtons Code): . - ' ' � �� - nooaess,2//D i�,� P� �p 9 Q 2 A ❑ I, as owner of�he properH, o�my employees wifh Q/Y � wages ai iheir sole compensation,will do the work ond � �the sVudure is not inlended or offered for sale(Sect(on ��N /GM� a� TEI.NO. #. . • . •8 7044,Business and Professions Code�. . .- � OWNER ❑ I,os owner of the property,am exdusively contracling ' •:•G Q�� wiih Ilcensed comractors�o construct ihe projed(Seo � �`�� � - � � � � � '� - tion 7044,Business and Professions CodeJ. � ADDRESS ' ° s 2 G.5 O c=i CONSTRUCTION LENDING AGENCY - ����� � Om� . , � ' ' � hi:NO. � '�"���"-� ��,� 6-H S I he�eby affirm that there is a mnstrudion lending ageney for the performante of Ihe work for whith fhis permit is issued CON7RAttOR Lj�� Q�� "� - -� , � (Set.3097.Civ.C.). � . } (� t,I Q ........ . . . . .. ADDRESS� �O �.J: CeI)�/� 7�' . _ ... . . ..� , � '. ' '' � . Lender's Nama CITY D f:��� TEL NO.'7,Z'Q�p 9 . .. - . . . . _ . -. lender's Address T STATE LIC, q�D I certify ihat I have reod Ihis applimtion and slata thol ihe - �ICENSENO. .Z�.LrP .1/ - CLa.55 CL _ . . _ , . ... . � , __ ..____ . .. _ .... ._. above informalion is torred.I agree to cdmply wilh all County . ordinances and Stote lows relating to boilding tonitrvttion, � "� . - , . _ _ _ , _ . _ and hereby authorize representotives of ihis Coonty to enter � � . � � � - - � � � � � n the obove- e +(oned property for ins ectto purposes. . SEE REVERSE FOR EXPLANATORY LANGUAGE � a .� d ia�eY _. _ �" SlgnaNre o(APPiiconl or Agenr Dafe ' - . . . ....-.. . . ...�.- .. .. . . . /,. �l . l./=�� • ' 1 . . - �''` `,� ` , � . . , '� ; . , , \ . , ' S1 1 � ` \ , • �.,� 1 ,` , � ' ..... ,-., � t �;' ,.'. 4 " _ ` � � " `�;�,:� � ' , ' , l,:y. \ t:% �. . . � i` i �;' .. , 'V � , . S.± _ , � �' V .. . `f", �, ''!;`' t. 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