HomeMy Public PortalAbout5039 SERENO DR_Mechanical__ WORKER I haveCOMPENSATION of consent
to 7�DPW B/t� APPLICATION FOR PERMIT LIME GREEN
1 FRrebYefflrl%thet I have a certificate of coneent to self Insure
or a cen(Iloate of Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy diersol(Sec 3800 Lpb C) -
Policy No DW 64, Company 5TR& COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Certified copy is hereby furnished
10 Cerulled copy is filed with the county building Inspection FOR APPLICANT TO FILL IN/ %/� T SUNNI
0 Lit!
depa�rtem�ent 1 tcenl (PRINT OR TYPE ONLY)
Dale ADDl
'—r—'"I-- � NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALRY
G
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCECROSSST
ABSORPTION UNIT BTU(ThisASSESSOR
perm"often for rm,h not be completed 0 the cork Involved by the MAP BOOK PAGE PARCEL
permit le lut one hundred dollen f the or len) AIR HANDLING UNIT CFM ayTrxT yygy m.
I certify that m the performance of the work for which this permit
is saved I shell not employ any person io any manner so as to BOILER BTU
become subject to the Worksite Compensation laws ' •�
�. COMPRESSOR BTU DQ
AFrrovAu DAM a 50"rUI e
Data � App lzMl VEllnLAT10N SYSTEM '
NOTIC TOA PLICANT II after king this C Illcate of ROUGH z3
44
Exemption you should become subject the Workers Compensation EVAPORATIVE COOLER -
prowslons of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU_GRAVRY -
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Bn- HEATERSUSPEN R_91 AL 4 5 v 4te
(commencing with Section 7000)of Division 3 of the Business and !� WALL
Profasel a cyte and my] enga�is in full force and effect
CCNumber LieClaes Q� }
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❑ I am exempt under Sac Plan check fee II4.�4 1 n i 3'11
oZ,7 7� O
B aP c for this reason PERMIT ISSUING FEES J. . 0
Date TOTAL FEE 7 7 a
Signature l
OWNERBUILDER DECLARATION PLAN CHECK APPLICANT _ _ `111 y't 117 a7� Z
I hereby affum that 1 am exempt from the Contractor a License Lew _
for the fallowing reason (Section 7031 8 Business; and Professions NAME
Code) ADDRESS n-HntfilE ,L iQ
❑ I as owner of the property or my employees with wages ,
e9 their sole compensation wlll'do the work and the CITY TEL NO
structure Is not Intended or offered for sale (Section 7044 -
Business and Professions Code) OWNER Q G r r td
❑ I as owner of the property am exclusively contractingt c-�
with Ilceneed contractors to construct the project (Sec ADDRESS 47 QQ q p 6 * to
non 7044 Business and Professions Code) + _
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there Isa construction lending agency for s t
the performance of the work for which this permit le IssuedTw`��
(Sec 3097 CIV C 1 -
ADDRESS
Lender a Name 7fi 97
CRY u TEL
Lenders Address
I certify that I have read the application and state that the above LICE E NO CUSS
Information s correct I agree to comply with all County ordlnantas t Y�
end State laws relating to building construchon and Hereby aulhonze
representatives of this County to enter upon the above mentioned ,
property forIn echon purpo s SEE REVERSE FOR EXPLANATORYLANGUAGE
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