HomeMy Public PortalAbout5034 SERENO DR_Mechanical__ affirmaffirmW that I certificate°°""PENSAn°"DEcwu"°" DPW89 APPLICATION FOR PERMIT LIME GREEN
I hereby em that have acertificate of consent to Bell Insure
or a certificeterol Workers Compensation insprance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sac 3900 Lab C)
Policy mpany 4 CoCOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Confined - reby lurrxmted
❑ Certified COPY is filed with the county building inspection FOR APPLICANT TO FILL IN BU
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ING
clapp"em _(PRNT OR TYPE ONLY)
DataLOCALITY
Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE n
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT BTU ASSESSOR
Q s
(This section need not be completed N the work Involved by the / MAP BOOK �jd PAOEO//�y
PARCEL -40
permit Is for one hundred dollars($100)or less I AIR HANDLING UNIT CFM (O D
oTwLT eO AtOCEaem er
I canny that in the performance of the work for which this Permit Lp
Is issued I shall not employ any person in any manner so ae to BOILER BTU
become subject to the Workers Compensation Laws
COMPRESSOR BTU
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Data Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should become subject to be Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or tots permit shall be deemed revoked FURNACE FAU RAvrry VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I em licensed under I provisions of Chapter 9 HEATERSUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code and my license is in full force and effect
%{ ' ACCT.'.
License Number Gv�Q,,�OLb Class 1%(/�L-i./ S rye 33Q�1 122.50 }
Contractor Agt*la C7Jr/)I2�de O'�,GC. 1 ITQ 7 O
❑ I am exempt under Sec - Plan Check fee { TOTAL 122 .50 ()
B eP C for this raemn PERMIT ISSUING FEE$ Q CIECK 1n.50 0
Date TOTAL FEE a NANE .008
Slgnatun D-
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT QOOO 01 4/ 3/96 ?
I hereby affirm that I am exempt from the Contractor a License Lew NAA(F ,
for the following reason (Section 7031 5 Business and Professions 1 AM 9:39
Code) ADDRESS
❑ I as owner of the property or my employees with wages
as their sole compensation will do the work and the CRY TEL NO
structure is not intended or offered for sats (Section 7044 '
' Bu ae end rofeaelons Code) OWNER
ne the property em exclusively contracting
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Proleeakme Code)
CONSTRUCTION LENDING AGENCY CITY TEL NO
1 hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is Issued COHfMCTOR -
(Sec 3097 Cly C) - r _ -
ADDRESS (
Lender•Name '
CT' ZA TEL NO do _
Lender a AddressSTATE LIC
I certify that I have read this application and state that the above LICENSE NO 36 CLASS
information is correct I agree to comply with all Coumy ordmancas
and State laws retating to building construction,and hereby eulhon to
repro utmetivee of this County to enter upon the ab�bo"veementioned
/ property for Inspects n urp e ----���r SEE REVERSE FOR EXPLANATORY LANOUAOE y`
oar