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HomeMy Public PortalAbout5043 SERENO DR_Mechanical__ WORKER S COMPENSATION DECLARATION 20-OW DPW 9f� APPLICATION FOR PERMIT LIME hereby affirm that I have a certificate of consent to self Insure 78A-gW LIME GREEN or a eehlficate of Worker s Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Secb C) Pol"No 10174 Company� r~ - COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ❑ Candied copy is hereby furnished r d 3 Cemeed cop/is filed with the county buildup i n . FOR APPLICANT TO FILL IN ewLWNO �1/D A- t (PRINT OR TYPE ONLY) ADDRESS 7 Dale � Applicanti NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEM M WORD NEAREST COMPENSATION INSURANCE CROSS ST ABSORPTION UNIT BTU (Thisperm t Is for Med not be completed 0 the work Involved by the MAP BOOK PAGE PARCEL permit Is for ono hundred tlo1Mro(1100)or leas) AIR HANDLING UNIT CFM I certify that in the performance of the work for which this permit Is issued I shall not employ any person in any manner so as to BOILER BTU J !O(JY L..A-dam become subject to the Workers Compensation Laws ,a �D COMPRESSOR BTU 0, AR1xIJNa wis omrectoee®eunxk Dale Applicant Vf1fITLATK)N SYSTEM NOTICE TO PP ICANT If alt n making this Qi1rifficale of ROUGH 7-3.9 Exemption you should become subl to the Work ererompensedloin provisions of the Labor Code you must forthwith comply with such EVAPDRATIVE COOLER FINAL U- provisions or this permit shell be deemed revoked FURNACE FAU_ORAVITY LCENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT 5D _ (commencing with Section 7000) of Division 3 of the Business and TER WALL 1914of lone Code and m I ansa Ig n lull force eM affect O �Q _ din I b93 6 /( - Lm Number Lx: Clew G��©- - .r0417-Cf _ I 1 EM!J >- Contractor J&qbr-amn Data '2 a I i T,;L 117 - 75 S an exempt under Sec Plan check fee =LIE I', 117.'° Q B aP C far this reason PERMIT ISSUING FEE E7s i,HAP IE ,ulI Data TOTAL FEE111-71 -75- - d SignatureQ. CHECK APPLICANT -dipp'.j' o,1 1/2 Q, 7 to OWNER BUILDER DECLARATION - c Z I hereby affirm that I em exempt from the Contractor a License Law NAME for the following reason (Section 7031 5 Business and Professions - - Code) ADDRESS ❑ I as owner of the property or my employees with wages 1,JI riL_ �4r 9C as their Bole compensation will do the work and the CITY TEL NO - structure Is not intended or offered for sale (Section 7011 Business and Professions Code) OWNER /T�rrp,J A �///� -HANI e'I, Elas owner of the property em exclusively contracting MAIL " G p� v ) r t with licensed contractors to construct the project (Sec ADDRESS C0 , vQ,JB—y tion 7044 Bumness and Profeasrons Code) CONSTRUCTION LENDING AGENCY CITY '�' TEL �'�>-7 I hereby affirm that there is a construction lending agency for - the performance of the work for which this permit le Issued COFACTOR �u /1, �fj- - — (Sec 3087 Civ C) O v ADDRESS 16j.9 Lender s Name CrrV TEL N vi 6 Lender s Address I certify that I have read this application and state that the above LICENSE NE SC E NO CLASS information Is correct I agree to comply with all County ordinances and State laws retailing to building conam chbri,and hmeby authorrse representatives of this County to enter upon the above mentioned property forI action pun a p�L/� SEE REVERSE FOR EXPLANATORY LANGUAGE 6gNAlURE6 CANT OR ADFM 1 DAM 77 //