HomeMy Public PortalAbout4922 SERENO DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have o certificate of consent to self
orsarcen�ed coW thereoor a certificate of f Workers 380 Compensation Insurance 7� HEATING - VENTILATING - AIR CONDITIONING
Pr ( )
Policy No Company ' Amb DPW 9/813 1 1 . - --
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
n"15enified copy is filed with the county building inspec- " FOR APPLICANT TO FILL IN BUILDING
tion deportment I I ADDRESS
1 (PRINT OR TYPE ONLY)
Date Applicant -NO TYPE OF APPLIANCE OR EQUIPMENT _ FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
, COMPENSATION INSURANCE - CROSS ST
(This stolon need not be campleted If the work irtvohed by ABSORPTION UNIT BTU
erDeTgKr BY
the pmtt is for one hundred dollar (1100)or less) OX
permit
I certify that in the performance of the work for wO//
hich this AIR HANDLING UNIT CFM h ,
permit is issued, I shall not employ any person In any manner ✓ V
so as to/���/aaa,,,cccomee subject to the Workers Compensation Laws BOILER BTU � APC ALS DATE �N Ou 5 SIGNATURE
Date coApplicant .4141A' 7-1" /1
COMPRESSOR BTU `s ,19& ROUGH
' ,NOTICE TO APPLICANT 'If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Worker
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V LID Tph
with comply with such provisions or this permit shall be deem- _ - - - '
ed revoked FURNACE FAU O
LICENSED CONTRACTORS DECLARATION FLOOR TU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business- - WALL
and Professions Code,and my license is in full force
+rand
�s effectect , }
License NumefrI Lic Classy
Contractor Dole ac
O
r
I am exempt under Sec V
Plan check fee
B 8P C for this reason d
Date PERMIT ISSUING FEE $ 2
Signature I I ITOTAL FEE -
OWNER-BUILDER DECLARATION PAN CHECK APPLICANT - •.
I hereby affirm that I am exempt from the Contractor a License
Low for-the following reason (Section 7031 5 Business and NAME polo. ,
Professions Code) O
❑ I as owner of the ro er ADDRESS _
p p sa or my employees with y
wages as than sole compensation,will do the work and ACCT•sr
the structure is not intended or offered fro sole(Section- CITY _ TEL NO 3207 38.1313
7044, Business and Professions Code) OWNER
❑ 1, as owner of the property, am exclusively contracting - 1 ITM
with licensed contractors to construct the project (Sec. MAIL
tan 7044 Business and Professions Code) ADDRESS TOTAL 38.00
CONSTRUCTION LENDING AGENCY '
CITY TEL NO /`lJC/+Va.�j
I hereby affirm that there u a construamn lending agency for 4r1GM
the performance of the work for which this permit is issued CONTRACTOR , CHANGE .00
ADDRESS 3097, Civ C ) _ -
ADDRESS
Lenders Name _ _ I _ -r�(-,tyr��.y�/ pr
CITY TEL NO _ GOW OMI - 1/LD�]LI
Lende(s Address STATE - uc - - - — — •- 8184 1 ,-AL1 9�k�
I certify that I have read this application and state that the LICENSE NOLIC
above information Is correct I agree to comply with all County
CLASS
ordlnances and State lows relating to building construction ' " ^ -' -- -
and h eby authorae representatives of this County to enter
t above-m ntioned property for in chajn purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
q Lure of Applicant or Ace t �
&t4, SEE