HomeMy Public PortalAbout5025 SERENO DR_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
P'herAby affirm that I have a certificate of consent to self '
insUPs"or a certificate of Workers Compensation Insurance,
or a certihedcopy thereof (Sec 3800, Lab C ) _ 76A364C HEATING - VENTILATING - AIR CONDITIONING
��V���/s� CE 818(REV 10/81)
Policy No AQ(� Company ✓� /6L . 1
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 hBUILDINSSG
on department Q � � nn (PRINT OR TYPE ONLY) ADDRE
Date 96 Applicant TUB / lJ rl� /,nr LOCALITY E
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS S7
(This stolon nwd not be completed H the work Imalrod by ABSORPTION UNIT BTU Disiaicr No PItOC v
' the permit Is for ons,hundred dollars ($100)or loss ) qIR HANDLING UNIT CFM p
I codify that in the performance of the work for which thisr O7J '
permit is issued, I shall not employ any person in any manner
so os to become subject to the Workers Compensation Laws BOILER BTU Al VALS DAM i Svc oR T E
Date Applicant COMPRESSOR BTU ROUGH 14 2
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 Code, you must forth EVAPORATIVE COOLER VALIDATION '
with comply with such provisions or this permit shall be
deemed revoked 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 Profess,ons Code
� and my license is in full force and effect
License Number_{��n771/")VJ Uc Class b/✓� - ► V
Contracto Tt haAE&. 1'n Dote U Jul66 "0
❑ I am exempt under Sec
Plan check fee L
N
B 8P C for this reason PERMIT ISSUING FEES `✓�9 Z
Dote
Signature TOTAL FEE
OWNER-BUILDER DECLARATION t . PIAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME
Professions Code) - -
❑ I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and
the structure ,s nat intended or offered for saleSection CITY TEL NO
7044 Business and Professions Code) ( _ b 2 2 A
❑ - OWNER j as owner of the property am exclusively contracting ` ` ` ` ` 8
wHh licensed contractors to construct the project (Sec- MAIL '
tion 7044 Business and Professions Code) ADDRESS I ` - 2(150
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for Oir TEL NO is 2Q506
the performance of the work for which this permit is issued CONTRACTOR -
(Sac 3097 C,v c ) ' . _ _ _ 1 1.25786 -
ADDRESS
.25c86ADDRESS
Lenders Name 114
L'
Lender s Address [�l
CITY O_ TEL NO
STA E LIC
I certify that I have read this application and state ;hat the =MSE NO CLASS —
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter
upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE_ _
Signature of Applicant w Agent -�