HomeMy Public PortalAbout4967-4969 SERENO DR_Mechanical__ RORI,P RS COMPENSATION DECLARATION 76A364C - .
1 hereby affirm that I have a certificate of consent to self CE 818 (4 90) APPLICATION FOR PERMIT
Insure or a c,ttifi,ate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 Lab C)
Policy No Com pan)
❑ Ccrtrfled copy is ht.reby Furnished COUNTY OF LOS ANGEL E� /'//� BUILDING AND SAFETY
❑ Certified copy is filed with the county budding mspcetion -FOR APPLICANT TO FILL IN BUILDING / �a 19k
department (D C. ✓ J
Dale Applicant (PRINT OR TYPE ONLY) ADDRESS 9
CLRTII ICATE OP EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE - LOCALITY—^�Ir �G� C �L
COMPENSATION INSURANCE �y f--� NEAREST n y
(This Section need not be completed if the Work Involved ABSORPTION UNIT BT90 D qv CROSS ST `/,/G/�/TJT
O
by the permit I5 for one hundred dollars (5100) or less) �//,�,, DISTRICT NO PRr- v dv U
1 certify that in the performance of the work for xhtLh this AIR HANDLING UNIT CFMd'�M'�—
permit is Issued I shall not employ am person to any manner _ �L/6 O
so is td become subject to the Workers Compensation Laws BOILER BTU
APPROVALS DATE INSPECTDRSS TORE
W
Date Applicant COMPRESSOR BTU ROUGH y
NOTICE TO APPLICANT If ettir making this Certificate of VENTILATION SYSTEM FINAL ?
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this perintt shall be EVAPORATIVE COOLER _ VALIDATION
deemed reokcd
FURNACE FAU— GRAVITY_
LILT LASED CONTRACTORS DEC(AR ATION FLOOR BTU -
1 hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPEND UNIT �l
9 (commencing with SLetlon 7000) of Division 3 of the Bust WALL ' 0"
ness and Professions Lode and my license is in full force and �—
effect
Lo.ense Number Lie Class
%T/ L
Contractor Dina
❑ I am exempt from the licensing requirements as 1 4m a
IlcenSed architect or a registered professional cngmttr Plan Check fee 25%Of above
xctmg to my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $
Lie or Reg No Date TOTAL FEE
HOML OWNF It BUILDER DECLARATION PLAN CHECK APPLICANT '
� z14.2A
1 hereby affirm that 1 am exempt from the 031 5 Contractors NAME ��
License Lax for [hc follow mg reason (Section 7031 5 Buy a �i` #
ness and Profesvmre Lode) ADDRES / L
1
es owner of the property will do the work and the - - - - - 2:• 3850
structure is not intended or offered for sale (Section CITY `,� TEL NO
7044 Business and Professions Code) OWNER _ • • • 3 8 5 0 6
F1I as owner of the property am exclusively cont protect 12 0 2--Pi
with licensed cu tit raU ors to cons[rUU the project MAIL
(Section 7044 Business and Profusions Code) ADDRESS
CONSTRUCTION LLNDIN6 AC,LNCY CITY TEL NO
I hereby affirm that there is a Lonstrucnun lending agency
for the performance of the work for which this permit is CONTRACTOR
issued (Sec 3097 Ci, C ) I•
Lender s Name ADDRESS
Lender s Address CITY t
I certify that 1 have read this application and state that the STATE _ om' w LIC
above Information is correct I agree to comply xrth all County LICENSE NO CLASS ,
ordinances and State laws regulating Hcatmg Ventilating end
Air Conditioning and hereby authonre mpresentalnes of this i SLI RF V F RSL POR LXPLANATORY LANbUAGE -
Countyenter upon the above me honed property for -
mspc n It sew
if`L/�Signature Permrt[ee Date
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