HomeMy Public PortalAbout5044 SERENO DR_Mechanical__ WORKLRS COMPLNSATION DECLARATION 76A364C - '
1 hereby affirm that I have a certificate of consent to self CE e,B lz BDI _APPLICATION FOR PERMIT
Insure or a cern Rcate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 Lab C)
Policy No Company
❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy IS filed with the county building inspection _
d artment FOR APPLICANT TO FILL IN BUILDING � ppp
Date Applicant ,(PRINT OR TYPE ONLY) AODRESSYO 7fuc,. L�Q�"DO r
LOCALITY
CLRTiriCATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE r
COMPLNSATION INSURANCE NEAREST >_
(This Section need not be completed If the work involved ABSORPTION UNIT BTV CROSS ST d
by the permit is for one hundred dollars ($IDD) Or less) DISTRICT NO PROCEaaE By 8
1 certify that in the performance of the work for'which thi AIR HANDLING UNIT CFM '�� cc
permit is issued I shall not employ any person i any m rn
so as to become subject to the Wor rs C i pe s o s BOILER BTV
y�y.��'�q� ']�/ 3O APPROVALS D TE n.P TORSSD TURE
Date.1S!/� nr Applicant—LAY _ COMPRESSOR BTU�C4[ �0� d
ROUGH y
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM ?
Exemption you should become subject to the Workers FINAL
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALID TION
deemed revokedG�Sy 11LL_
LICENSED CONTRACTORS DECLAR ATION FLOOR CE FABTU��v4YY 3o G
1 hereby affirm that 1 am licensed under pruxstons of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bust WALL
ness and Prnfeinons Code and my license is in full force and
effect .��
License Nupmb�e�r AeN-04-Y Lit Class�ZP 1
Contractor?,IT.Au�&0,fV) Date +V_ w_ff4-
❑ 1 am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer Plan Check fee 25%Of above
-actmg in my professional capacity (Section 7051 Bus
mess and Professions Code) I PERMIT ISSUING FEE $
Ltc or Reg No Date I TOTAL FEE
HOMF OWNER BUILDER DLCLARATION PLAN CHECK APPLICANT
1 hereby affirm that 1 am exempt from the Contractor s NAME,
License Law for the following reason (Section 7031 5 Bust
neer and Professions Code) - ADDRESS
I as owner of the property will do-the work and the CITY TEL NO R 085 A
structure is not intended or offered for sale (Section
7044 Business and Professions Code) 0 � 0 0
F1OWNER IGGf.� S V/lG IeN- # 8
I es owner of the property am axcluvvely contracting
with licensed contractors to construct the project MAIL L t • • 7 O 5 O
(Section 7044 Business and Professions Code) ADDRESS N .J u
CONSTRUCTION LENDING AGENCY CITYA414B.pI g>(t.J4. eA TEL NO • 705O�S
1 hereby affirm that there is a construction lending agency
for the performance of the work lot which this permit is CONTRACTORµ 44A4l#V'.J !L f N &Av' ( 01 0-84
issued(Sec 3097 Civ C )Lende , ` -
issued See 30 qpD RESS N tLC'
Lender s Address
I certify that 1 have read this application and state that the STATE 1"G LIC
above information Is wrrect I agree to comply with all County ENSE NO 0 CLASS
ordinances and State laws regula mg atmg Ventilating and
Air Conditioning a d here io a representatives of this SEE REVERSE 1 OR EXPLANATORY LANGUAGF
County r up It mentioned property for
in ct es
Signature of Permittee Date