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� 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 permif is for one hvedred dollars(5100)or lees.)
, 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 sl�udure is not inlended or offered for sole(Sect(on ��N /GM� (1� 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 representatives of this Coonty to enter � . � � � - - � � � �
� n the obove- e +(oned property for ins ectto purposes. . SEE REVERSE FOR EXPLANATORY LANGUAGE
� a .� d ia�eY _. _
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