HomeMy Public PortalAbout5011 SERENO DR_Mechanical__ WORKERS that COMPENSATION a ONULCLAfATION CE 81 D APPLICATION FOR PERMIT-
insure
hereby affirm That I have a certificate of consent to self
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insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a certified co�,/ttherreoof^(SL c 3800 1 C )
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Pnllcy No� •_,& Company_( �/�✓y COUNTY OF LOS ANGELES �� BUILDING AND SAFETY
,�, Certified copy Is hereby furm,s 5JJ
IpL Certified copy n fled vnth+y in )rKu;Idtng�reci ion I BUILDING
d+mar n � O
FOR APPLICANT EO FILL IN /
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(PRINT OR TV PE ONLY)
ADDRESS D�
LOCALITY ���
CERT11 KATE Of LXEMPTION I ROM' ORK RS NO TYPE OF APPLIANCE OR EQUIPMENT FEE _
COMPENSATION INSURANCE NEAREST }
(This Section peed not be completed If the work involved ABSORPTION UNIT BTU CROSS ST Y oa
by the permit Ls for one hundred dollars (SI00) or less) DISTRICT NO N I'ROCESSE Y _ (J
1 certify that In th. Performance of the work for which this AIR HANDLING UNIT CFM /' Ol%
permit Is Issued I shall not employ any person in any manner ✓I• Q
so as to become subject to the Workers CompLnsatlon Laws BOILER BTU UC
APPROVALS DATE INSPECTOR SSIGNATURE W
Date ApplicantCOMPRESSOR BTU__ — ROUGH V)NOTICE TO APPLICANT If atter making this Cerb(scale of VENTILATION SYSTEM Z
Exemption you should become subject to the Workers FINAL
Compensation provision, of the Labor Code yno must forth EVAPORATIVE COOLER VA' 'DATIO
14
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAURAVITV �
I LICENSE[)CONTRACTORS DI CLARATION / FLOOR B U
1 hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT yell,
9 (commencing with Section 7000)of Division 3 of the Bust ° WALL
ness and Professions Code, and my license Is in full force and
effect
Lignse Numbs Lic Class_`/ �Q
CDntractoo ata_
0 1 am exempt from the I1CLn%mg requirLments as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above
acting in my professional capacity (Section 7051 Bus
Ines%and professions Code) PERMIT ISSUING FEE $ f�
Llc or Reg No Date TOTAL FEE (1
HOME OWNER BUILDER DECLARATION PLAN,CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors FAD
E �_ '
License Law for the fnliow•ng reason (Section 7031 5 !Bust
F1ness and Profesmons Cod-) . RESy /j 1 as owner of the property wJi re rhe work end the // �d TE NO �3 b37 A
StruLtUreow is nn[ intended or offered for sale and(Stctionthe /lVJ/'111RR��V // , ,_I
7044 Business and Professions Code)
❑ OWNER" # •�• 8
1 as owner of the property am exclustvLly contracting
with licensed wn[ractors to construct thL project ) MAIL 21�I� 3&'5�
(Section 7044 Business and Profes%lons Code) ADDRESS
CONSTRUCTION LLNDING AULNCY CITY TEL NO 3850,5
1hereby affirm that there is a Lonstructmn kndmg agency ,
for the performance of the work for which this permit is CONTRACTOR L / 0303-8'2
issued (Sec 3097 Cry C) _
1 ender's Name ADDRESS/O�/_��—�/D
Lender's Address CITY x TEL NO
1 aruf) [hal I ha%c read this application and state that [he STATE ��---// LIC
abo%e Information is cnrrut I agree to comply with all County I LICENSE NO CLASS
ordinances and Stab, laws r -ulatmg Hwting Vrnhlahng and
Air , trios, 8 and hLr authorue r prese nlulnea of this SEE REVERSF I ORE 'LANATORY LANGUAGE
Ct my to n uI�o th ebo%e me honed property for
sPLutnn is,
Sign 're of Yerm1 _c Dale