HomeMy Public PortalAbout4928 SERENO DR_Mechanical__ t'�— WORKERS COMPENSATION DECLARATIcQN
ureW affrm that I have a certificate of consent to self APPLICATION FOR PERMIT
sura aria certificate of Workers Compensation Insurance - HEATING • VENTILATING - AIR CONDITIONING '
or a certified copy thereof(Sec 3800 Lab C ) CE 818(REV IOiBt) - -
Policy No Company
Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING t�11
tion department ADDRESS N'
(PRINT OR TYPE ONLY)
Date Applicant - LOCALITY ,4,
NO .TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST Ir� ll
COMPENSATION INSURANCE CROSSST VS Yyl� G I U O
(This rection need not be completed It the Mork Inwlsred by ABSORPTION UNIT BTU 7DISTR� D PROs Y
the permit Is For one hundred dollars ($100)or less )I certify that in rhe performance of the work for which thisAIR ttANDLIPIG UNIT CFM / O
permit is Issued, I shall not employ any person In any manner
so as to become subject to the Workers Compensation Laws BOILER BTU .w.d APPROVALS DATE INS TOR S SI RE
Date Applicant COMPRESSOR BTU Z7U i� ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers _
Compensation provisions of the Labor Cade you must forth EVAPORATIVE COOLER VALIDA ON
with comply with such provisions or this permit shall be '
deemed revoked I FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 and effect
d
O
License Number Llc Class - - ► V
Contractor Date - - • 0
❑ I am exempt under Sec raVi
Plan check fee w
B 8P C for this reason PERMIT ISSUING FEES AOL Z
Date
Signature TOTAL FEE5��r
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License Q
Law for the following reason (Section 7031 5 Business and NAME Pilo
�O r
Professions Code) I (y
❑ I as owner of the property or my employees with ADDRESS • v � � Q
wages as their sole compensation will do the work and CITU TEL NO o
the structure Is not Intended or offered for sole(Section
7044 Business and Professions Code) - - - - '
OWNER
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL ,
hon 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY - CITY - TEL NO --
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is Issued CONTRACTOR ,
(Sec 3097 Gv C ) - _
ADDRESS
Lenders Name
CITY TEL NO
Lender sAddress - "- -
I certify that I have rood this application and state that the LICENSE NO CLASS
above information Is correct I agree to comply with all County
ordinances and State lows relating to building construction,
and hereby GUthO"Ze representatives of this County to enter -- - --
upon the above ma honed property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
11 Signature of Applicant or Agent Date