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` �- "'°RKERS•`°""PE"SAT�°"°E"''R`'"°" qppLICATION FOR PERMIT �
I hereb,y affirm that I have o certificate of consenr to self
insure,or a certificate of Workers'Compensation Insurance, 76q36ac , „_...__ .H.E�TIN.G ',VENTILATING - AIR CONDITIONING
or a certified thereot(Sec 3800, C.) - -�-�� - � �
CE-818(REV.10'811
Policy .���
� certifed copy is hereby furnished. - COUNTY OP LOS ANGELES BUILDING AND SAFETY
ertified copy is fi�ed with the ro n ilding inspeo FOR APPLiCANT TO FILL IN euaDING �}� �y
lion de art enf. ADDRE55 L�-
�PRINT OR TYPE ONLY;
Do� � i �PPlicant iOcaiiiY �� .
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARES' " �
COMPENSATION INSURANCE CRO55 57.
(This section need nof be complefed if}he work imelved by ABSORPTION UNiT,BTU ms*eicr�o. �aocessee av
fhe permit is for one hundred dollars(5100)or less.) qIR HANOLING UNiT,CF:M � �^ �'
I certify thot in the performance of ihe work for which this i` � S`0'� �`���`,,
permi:is issued,I sholl not employ ony person in any monner � ��'�� �
so as to become subjeci to the Workers'Compensation Laws. gOILE.4,B7U a.�pRovqLs DatE INSPE:'oa'S SIGNA"JRE
Date Applicant COMPRESSOR,BiU �� �V ROUGH
NOiICE TO APPLICANT: It, after mpking this Certificate of VEN71�A710NSYSTEM F�NAL -' � . ���
Exemption, you shoold become subjed to ihe Workers' �
Compensation provisions of ihe Labor Code,you musf forth- EVAPORAiIVE COOLER VALIDATION
with comply with such provisions or ihis permit sholl 6e
deemed revoked. FURNaCE FAU � ��
LICENSED CONTRACTORS DEGLARATION FLOOR B7U
I here6y affirm fhot I om licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
(commencing with Sedion 7000)of Division 3 of the Business � WALL
and Professions Code,and my license is in full force and effecl. �
License umber I���� Lic.Clqss�� , v"
:,� g,'
����o � �
�
❑ I am exemp under Sec. � �
Plcn check fee �
B.BP.C.for this reoso� PERMIT ISSUING FEE$ �Q . Q �
�ate:
Si9�at�re TOTAL FEE
OWNER-BUILDER�ECLARATION PLAN CHECK AF>FLiCAVT .
I hereby affirm ihat I am exempl from fhe Coniroc'or's License -
Low for the following reason(Sec�ion 7031.5, 8usiness and NAME �<,C�'����r'1�.
Professions Codei:
❑ �, as owner of fhe property, or my employees with ADDR:SS a�' " ' " �'�
wages as their sole compensdtion,will do the work ond CITY TEL.NO. t " � „��i'
the struc�ure is not intended or offered for sale(SecYion '
7044,Business and Professions Codel. � y � �, {^,v =
OWNER -.- i�-�
❑ I,as owner of�he praperty,am exdusively controUing
wiih licensed coMractors w construct ihe proje:t(Sec- qpjRE55 ,�j'y u e:�.i E�"'�[i
tion 704G,Business and Professions Code).
CONSTRUCTION LENDING AGENCY Ciiv �;� 7EL iv0.
I hereby affirm thaf fhere is a construction lending agenty for
the performonce of fhe work for which this permit is issued 1_S� .�
�Sec.3097,Civ.C.1. �vl'^�
ADD2ES5 a �,
Lender's Name ��
CITY TEL.� �.. �C�
Lender's Address
STATE LIC.
I certify thoi I have read ihis application and state�hat the LICENSE NO. , CLA
above informo�ion is<orrect.i agree to comply with oll Couny �
ordinonces d State laws relating to building wnsiroction,
-and here 1 ize representatives o ihis Courty to enter
upo ihe m mio d property for inspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
}
Signa!ure of Aoolimnt or Ag ate
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