HomeMy Public PortalAbout5066 1/2 SERENO DR_Mechanical__ WORK[ RS COMPCNSAI ION DEC ORATION CE 81C APPLICATION FOR PERMIT
I hereby affirm that I hale a Lerbfican of consent to self CE B78 (2801
insure or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
acerr,,o copy thereof(Sec 3800 Lab C) f
Po icy o _051829ompany_Fremont ( COUNTY OF LOS ANGELES � '� ' BUILDING AND SAFETY
❑ Certified copy is hereby furnished
Certificlepy is filed with the Lountw budding inspection
di artment FOR APPLICANT TO FILL IN BUILDING
p ADDRESS 5066 Sereno—Dr.
Date-V16/83Apph,ant Kamor_A1r—Coad-- (PRINT OR TYPE ONLY)
LOCALITY
C RTj FICATL 01 EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE Te_�[{p�£—Cit
CONIPLNSATION INSURANCE II NEAREST
(Thi ti n need not be completed If the work involved 1 ABSORPTION UNIT BTU Cfl OSS ST a
by the permit is for one hundred dollars (SI00) Or less) DISTRICT NO PRocE55 ev �- U
I ctrtify that in the performance of the work for whi,h this AIR HANDLING UNIT CFM
permit 6 issued I shall not Lmploy any person In am manner �;e O
so as to become subject to the WorkLrs Compensation Laws BOILER BTU 0
APPROVALS DATE INSPECTOR SSIGNATURE
Date Applicanta COMPRESSOR BTU ROUGH d
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL xemption you should become subject to the Workers FINAL 2 Z
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comply with such prusisions or this permit shall be
deemed res oked FURNACE FAU X rfftlO OOVITY 33
LICENSI DCONTRACTORS DECLARATION FLOOR BTU—
I
I ?;7
I hereby affirm that 1 am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi WALL
ness and Professions Code and my license is in full fort, and
effeLt
License Numb,r_165064— Lie Class—C=20—
Contractor Kamor Air Date 9/16/83
❑ 1 am exempt from thL licensing reyuir,inents as 1 am a
licensed architect or a registered professional engineer Plan Cheek fee 25% Of above
acting in my professional capacity (Section 7051 Bus
mess and Professions Code) PERMIT ISSUING FEE $110
Lie or Reg No Date TOTAL FEE 3O 5O
r
HOME OWNER BUILDFR DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractors NAME 2 5 4'0,0 A
License Lew for th, following reason (Section 7031 5 Busi j
nss and Professions Codi,) ADDRESS
p . . . . . 8
❑ I as owner of the property will do the work and theme CITY TEL NO 2 • • 30 50
structure is not intended or offered for sale (Section i
7044 Business and Professions Code)❑ OWNER •+'0 • 3 0 5 0 5
I as owner of the property am exclusively contracting Mr. and MrS. LarryPan
with licensed contractors to construct Ih, project MAIL 09 20-83
(Se,fion 7044 Business and Professions Code) ADDRESS .806.6�Sereno-DL ,
CONSTRUCTION LENDING AGENCY CITY Temple City TEL NO 2874373
1 hereby affirm that then. is a Construction lending agency
fur the performance of the sxork for which this permit is CONTRACTOR KamO3 AT r C ,
issued (Sec 3097 Civ C)
Lenders Name ADDRESSi
60- __S_a
Lenders Address CITY TEL No 7957523
1 certify that I have read this application and stale that the
—Pasadena
STATE LIC
above information is correct 1 agree to comply with all County LICENSE NO 165 CLASS —
ordman,e and Slate laws regulating Heating Ventilating and
Air Conditioning and hereby authorize representatives of this SEF REVLRSL I OR EXPLANATORY LANGUAGE
County to enter upon the above mentioned property for
inspection purposes
Signature of Permittee Dale