HomeMy Public PortalAbout5048 SERENO DR_Mechanical__ WORKERS cbMPENSATIONDECLAR^TION -- 76"364°
CE 818 (2 80-80) - APPLICATION FOR PERMIT
1 hereby affirm that 1 have a certificate of consent to self
, u
insure or a certificate 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 BUILDING qA (��
_department FOR APPLICANT TO FILL IN ADDRESS 67Nt(J Ab , &_4?,9e00
Date Applicant (PRINT OR TYPE ONLY) /^• ,(
LOCALITY`�GM P& C•1-
CLRTIEICATL OI EXEMPTION CROM WORKLRS NO TYPE OF APPLIANCE OR EQUIPMENT FEE 11
COMPENSATION INSURANCL NEAREST t
CROSS ST CL
(This ae perm need n0[one
hundred
ted if the Work involved ABSORPTION UNIT BTU O
' by-the permit is for otte hundred dollars ($100) or less) DISTRICT NO Pnocla av U
1 cerbq that in the performance of the work for sv ch /,1 AIR HANDLING UNIT CFM ,/ ccpermit is issued 1 shall not employ ty pe s n I a m •Q e+ 0
so as to become subleCt to the \vr r n ns on aBOILER BTU APPROVALS DA INS IT RSSIGNAT RE
-Da
(��. (�,,.,.� W
Dat t+'-' pplKant COMPRESSOR BTU V_[!_LL-- Q BOUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM Z
Exam peon 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 shdll be EVAPORATIVE COOLER �J VALID ION f/
deemed revoked r ^� FURNACE FAU /3BAYILY�— - /
LICENSLD CONTRACTORS DECLARATION i FLOOR BTU-&V CeCeIO
I hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commenting with Stenon 7000) of Division 3 of the Bust WALL
ness and Professions Code and my license is In full force and
effect
License Number�}( 31 ,Q V Lic Clads
Contmttor�IT/FI1 a_AN-CQ Date
❑ I am exempt from the licensing requirements as 1 am a
licensed architect or a registLred professional engineer Plan Check fee 25% Of above
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $ /p L)
Lic or Reg No Date - TOTAL FEE It.) S
HOML OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
hereby affirm that I am exempt from the Contractors NAME
License Law for the following reason (Section 7031 5, Busi
ness and Professions Code) ADDRESS 2 0 8 S 3 A
❑ 1 as Owner of the property will do the work and the
structure s not intended or offered for sale,(Section CITY /� TEL NO # 8
7044 Business and Professions Code) OWNER/ Z 1 I I a 1, 70 Jr 0
F11 as owner of the property am exclusively contracting W �-� SL
with licensed contractors to construct the project MAIL A 1]�� '�0 Jr 0
(Section 7044 Business and Professions Code) ADDRESS 141/..) T a
CONSTRUCTION LENDING AGENCY - CITY fµrLvt ag_4_ TEL NO J01Oc-`84
I hereb) affirm that there is a construction lending agency
for the performance Ot the work for which this permit is CONTRACTOR " L7Q ¢ qd.1 b �O
issued (Sec 3097 Co,CC) A _ —
Lender s Name ADORES ITf♦�����
Lender s Address i CITY eK ta-1AL TEL NO
I certify that I have mad this applies n and s1etL that the STATE q/ LIC Tn
above informations t
correct agree ply with all County LIC EN NO O CLASS
ordinances and State laws gulati o Ung ventilating and -
Air Condo nmg n er y a r representatives of this SEE REVLRS6 1 OR LXPLANATORY LANGUAGE
Coum ent n he enboned property for
m e r por /
—/p•
Signal re of Permittee Data