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Home My Public Portal About5066 SERENO DR_Mechanical__ WORKCOMPENSATION DECLARATION DPW9/es APPLICATION FOR PERMIT LIME GREEN I heregy affirm thattIhave have a certificate of consent to Bell Insure or a certificate of Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec 3800 Lab C) Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ' ❑ Carolled copy a hereby furnished ❑ Cerdfled spy a filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING departiilerll (PRINT OR TYPE ONLY) ADDRESS/1/. E E Da Date Applicant LOCALITY + NO TYPE OF APPLIANCE OR EQUIPMENT FEE 9 Ins CERTIFICATE OF EXEMPTION FROM WORMERS NEAREST COMPENSATION INSURANCE CROSS ST — PAfw (This section need not be completed It the work Involved by the ABSORPTION UNIT BN ASSESSOR permit Is for one hundred dollars($100)or lees) AIR HANDLING UNIT. MAP BOOK PAGE Q 12PARCELQ CFM pargpr rx) YnOCE9ED sY 1 cenity, that In the to employ an of the work for which this permit /rte ^ a become 1 •hell not employ any person In any manner so as to BOgFR BTU become subject to the Workers Compensation Laws 1 COMPRESSOR BTU Data Applicantxmnov+ua Dore .®ccmeeeaaxrixa: VENTILATION SYSTEM NOTICE TO APPLICANT If alter making this Certificate of ROUGH Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER Provisions of the Labor Code you must forthwith comply with such FINAL provlelora or this permit shell be deemed revoked FURNACE FAU GRAVRY LICENSED CONTRACTORS DECLARATION I FLOOR BTU Z Z VALIDATION I hereby affirm that I em licensed under provisions o1 Chapter a - (commencing with Section 7000)of Division 3 of the Business and HEAD UNIT_ SUSPENDED ENDED Professions Code and my license Is In full force and effect License Number Llc Class _ a Contractor Date 8 ❑ I am exempt ander Sec Plan check fee - V + Q B AP C for this reason PERMIT ISSUING FEE$ 2 O Date TOTAL FEEQ Q r Wit Slgrwua co OWNER BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor a License Lew NAME for the following reason(Section 7031 8 Business and Professions - - , ACCT.: + ADDRESS a Tr [e 'k, ^Ji_Itf I as owner of the property or my employees with wages M' ] TV.W as their sole compensation will do the work and the CITY TEL NO - ♦�kl� structure is not Intended or Offered for 3818 (Section 7044 1 ITM Business and Professions Code) '" TOTAL ❑ _ I as owner of the properly am exclusively contracting MNL QN � 4� [��M with licensed contractors to construct the project (Sec ML ESS Q I 70 D (. CAStI .VLI hon 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY C C TEL NO agd •00 I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is Issued CONTRACTOR (Sec 3087 Civ C 1 , La, ADDRESS yyyo—Wt,l Lvl-v'r Lender a Name 642] 1 _ Aft 9:44 CITY I TEL t10 _ Lender a Address LI I certify that I have read this application and state that the above LICENSE NO LIC ASS information Is correct 1 agree to comply with all County ordmencee and State laws relating to building construction and hereby authorize ((((((��eeeeggqqqqrrrrrraserltatives of this County to enter upon the above-mentioned party for Io tlo t Poses SEE REVERSE FOR EXPLANATORY LANGUAGE SIONADh1►�'9L RII E OF Ar41J R,a AGENT wre 20-O arm that I have a certificate DECLARATION 76AS DPW 9188 APPLICATION FOR PERMIT LIME GREEN 1 hereby affirm ihel I have a certllicete of consent to telt Insure �� or a chereof(i of Worker a Compensation Insurance or a certified `. ; HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec 3800 Lab C) - _ Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ❑ Certified copy is hereby funxahad ❑ Certmed�Y is wed with the county building Inspection FOR APPLICANT TO FILL' IN - BUILDINO O deperbnem (PRINT OR TYPE ONLY) ADORE56 66 At SCM10 Data ApplicantLOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST — C C 1,411 ZA ABSORPTION UNIT BTU ' COMPENSATION INSURANCE CROSS Sr �� ('' F (Thisperm t Is for need not W completed($1 0 the work Involved by the MAPS BOOK PAGE 012- PARCELOA,6 ' IlerniN It for ono hundred dollen f he or leer) AIR HANDLING UNIT CFM oiemcr in vaoomw er I certlty 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 become subject to the Workers Compensation Lowe ,3 S roN' COMPRESSOR BTU .sniovus Mm irmxcroe a 00 un Date Applicant VENTILATION SYSTEMNOTICE TO APPLICANT It alter making this Certificate of BOUGH Exemption you should became subject to the Workers Compensation �,I I provisions of the Labor Code you must forthwith comply with such EVAPORATIVE FINAL provisions or this permit shall be deemed revoked FURNACE FAU—GRAVITY _ LICENSED CONTRACTORS DECLARATION FLOOD BTU VALIDATION ' I hereby affirm that I em licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT_ r ? (commencing with Section 7000)of Division 3 at the Business and WALL 89 Professions Code and my license is in full force and effect ACCT.: � License Number Llc Class C Poo. >__ I, ' 3307 •JJ 1 Contractor III.Date _, pp El am exempt under Sec Plan check fee _ _ TOTAL 50. 55 U B aP C for this reason PERMIT ISSUING FEE S (ASH `•id• -n ¢O DateTOTAL FEE W Sigrielure OWNER BUILDER DECLARATION PLAN CHECK APPwGNT 1 N 5/11/93 z I hereby affirm that I am exempt from the Contractor a License Lew PIAjdE , for the folladng reason (Section 7031 5 Business and Professions 9645 1 AM 9:03 ige) i ADDRESS I as owner of the property or my employees with wages as their sole compensation will do the work and the CRY , TEL NO structure Is not intended or offered for sale(Section 7044 slnesn end Professions Code) OWNER SujRAymp 8 !F F ApORE ❑ I as owner of the property am exclusively contractingL- with licensed contractors to construct the project (Sec SS50,66 A/. 'SE-REA10 Dq tion 7044 Business and Professions Code) - np CONSTRUCTION LENDING AGENCY CITYkmplF 0,,x TEL NO aC.O —0 D a I hereby affirm that there lea construction this sperlending agencs for CONTRACTOR the performance of the work for which this permit 4e leeuetl (Sec 3087 Cm C 1 ADDRESS Lender a Name CITY TEL NO , Lender Address STATE I certify that I have read this application and elate that the above LICENSE NO CLASS mformabon is correct I agree to campy with all County ordinances and State laws totaling to budding conebuchon and hereby authorize i r entativae of this County to enter upon the above mentioned op rty,for Inspe to ur a SEE REVERSE FOR EXPLANATORY LANGUAGE All Ano est��.�i-93 n urt oa Aoexr - Mira