HomeMy Public PortalAbout5041 SERENO DR_Mechanical__ WORKER I have a certificate
of con DECLARATION DPY91� APPLICATION FOR PERMIT LIME GREEN
I,hereby el4rm that 1 have a certihcete of consent to self insure
or a certificate of Werker a Compensation Insurance or a certified HEATING•VENTILATING •AIR CONDITIONING '
copy thereof(Sec 3800 Lab C) - - ,
OcY'NO ,9�CO1°p°"r' -�fj " " ' "�lyp COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS '1 WILDING AND SAFETY DIV
Certified copy is hereby furnished ,5D 4!
CCe�ilNtl copy tit filed with the county building Inspection FOR APPP�LICCANNT TO T OR TYPE FILL IN , eulLDwo
ADDRESS i
Date �APPIIreni ' LOCALITY
fq TYPE OF APPLIANCE OR EQUIPMENT FEE G�
CERTIFICATE OF EXEMPTCN FROM WORKERS - NEAREST
COMPENSATION INSURANCE CROSS ST
ABSORPTION UNIT BTU ESSp
(Thisaction need noted completed If the work Involved by the =BOOK
perm N onPAGE PARCEL
permit for e hundred dollen(f 100)or Nu) NR HANDLING UNIT,CFM nwc
or ao wncessm e.
I oemty that In the performance of the work for which this permit ,
Is issued I shell not employ any person in any manner so as to BOILER BTU O 9
become subject to the Work ere Compensellon Lowe sJ o
COMPRESSOR BTU �J
Date y Z y c117A + u 76 ArniovNa are ,yvmsectc�ls ewAnxa
NOTICE TOA PL ANT If after n this C9r (cafe of VENTILATION SYSTEM
Exemption you Should become subject a Workers penaatlon ROUGH
EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with each FINAL
provisions or this permit shall be doomed revoked FURNACE FAU_GRAVfTY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION �-
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPEN UNR
(commencing with Section 7000) of Division 3 of the Business and Z HEATER WALL 7�
,�grWsealons Code and my license le In full force and effect
IO(q3 S - 3 0
License Number LIC Class G 20 2 £ O -r -
1_li0-
; _'0
-
_O
Plan check fee - 0
I earl exempt under Sac Q
B RPC fpr this,seen PERMIT ISSUING FEE E Zq, 71 O
Oats TOTAL FEE J 4_'_ .i , W
Signal= 1 i7.75 a
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT 33107z
I hereby affirm that I am exempt from the Contractor a License Law NAME - 1 T 1 til'- ?
for the following reason (Section 7031 S Business,and.Professions , r
TOTAL 117 _ 7
Code) ADDRESS
I as owner of the property or my employees with wages t F{Eu_Y� 117.75
as, their sole compensation will do the work and the CRY TEL NO .T�(
structure Is not intended or offered for sale(Section 7044 f`t
Business and Professions Code) OWNER vryQ S Jr J Cif n
I as, owner of the property em exclusively contractingMAI (I /r' -r
with licensed contractors to construct the proieet (Sec ADDRESSU70 Ir—p jy,7 lil-IJ11--OI]I]1 1 ��"•�
tion 7044 Business and Proleaslons Code) i
CONSTRUCTION LENDING AGENCY crryixpmd.
L�r' TEL NO O 1402 1 AI's 11'1�7
I hereby affirm that there le0 construction lending agency for ' . /w
the performance of the work for which this permit 4a issued CONTRACTOR _
(Sac 3097 Civ C)
ADDRESS Ig r&6- ,
Landera Name "
CITY if TEL NO lb&
Lender a Address STATE M� LIC
I certify that I have read this application and state that the above LICENSE NO CLASS
Information is correct I agree to comply with all County crdmancee /LSO`— l
and State laws relating to building coneWcdthora
on,and hereby aue 4
representatives of this County to enter upon the above-mentioned
property for s pectl mn pllryoses SEE REVERSE FOR EXPLANATORY LANGUAGE