HomeMy Public PortalAbout5076 SERENO DR_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I herby affirm that I hove a certificate of consent to self
insure or a certificate of Workers Compensation Insurance HEATING • VENTILATING • AIR CONDITIONING
or a c9rtnied copy th/ereaff ca, 3800, Lab C ) 76A3MC '
Polity Nop�„ copy is hwio upon . 20 oW6 DPW 9iee -
y COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certi6 copy is hereby furors
Certified copy is filed with the county budding mspecFOR APPLICANT TO FILL IN BuIIDNG
hon Appl
de rtment DDRES
AS
(PRINT OR TYPE ONLY)
Date icant t LOCALITY
_ NO TYPE OF APPLIANCE OR EQUIPMENT _ FEE el 7Y
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
\ I COMPENSATION INSURANCE CROSS ST
(This section need not be completed R the work involved by ABSORPTION UNIT BTU gSTRICI ni0 PROCESSED BY
the peri Is for one hundred dollars($100)or loss)
I certify that In the performance of the work for which this AIR HANDLING UNIT CFM
permit Is issued, I shall not employ any person in any manner
"SD as't0 become subject to the Workers Compensation Laws BOILER BTU �{ APPROVALS MR INSPECTOR S SIGNATURE
Date Applicant COMPRESSOR BTU �` ROUGH 0
NOTICE TO APPLICANT If, after making this Certificate of _ VENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers '
Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER VALIDATION
with comp]y with such provisions or this permit shall be deem-
ed revoked FURNACE FAU GRAVITY
LICENSED,CONTRACTORS DECLARATION �V6 FLOOR BTU /51- '
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED-UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect
License Numb Lc Class &-2 Q , L
V
Contracto �flety� oL
❑ I am exempt under Sec c G
Plan check fee —
B 8P C for this reason N
Date PERMIT ISSUING FEE $ — _
T _
Signature TOTAL FEE
OWNER BUILDER DECLARATION RAN CHECK APPLICANT "
I hereby affirm that I am exempt from the Contractor s License ,
Low for the following reason (Section 7031 5 Business and NAME - -
Professions Code) 1
❑ I as owner of the property or my employees with ADDRESS _ If
wages as their sole compensation, will do the work and ACCT_`
the structure is not intended or offered for sale(Section CIN _ TEL NO
7044 Business and Professions Code) 3307 37.03
I os owner of the property,
OWNER
p perry, am exclusively contracting
with licensed contractors to construct the project (Sec MAIL 1 ITEtl3
tion 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY , CITY M8N �.� IZXL NO TOTAL
37 0d
I hereby affirm that there is a construction lending agencyfor
the performance of the work for which this permit is issued CONTRACTOR V,/
cp
(Sec 3097, Civ C )
ADDRESS _
Lender's Name 't-
Lender's
Lende/ s
s Addres . Z_ TEL - 7s� - - - _ 000MMI 10/ 9/90
1 certify that I have read this application and state that the STATE
ENO LIC A55 Cd d f 3212 1 F 9:44above information is correct I agree to comply with all County
LICENSE ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter
the obove-mentioned pro erty for inspection purposes - - -
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant Ape