HomeMy Public PortalAbout5078 SERENO DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
.I hereby affirm that I have a certificate of consent to self
+nsure oNa cgrtificate of Workers Compensation Insurance, HEATING - VENTILATING • AIR CONDITIONING
&r o9ceoffieB copy thereof Sec 3800, Lab C ) 76A364C
x, D N 20 0046 DPW 9788. -
1.,, t,
Policy No of Deny COUNTY OF LOS ANGELES BUILDING AND SAFETY
- ❑ Cenrfled copy is hereby furnrs e
rJQ Certified copy Is filed with the county building mspec- FOR APPLICANT TO FILL IN BUILDING
Y` tion department ADDRESS �Q
(PRINT OR TYPE ONLY)
Date O 0 Applicant LOCALITv � G T
NO . TYPE OF APPLIANCE OR EQUIPMENT FEE
RTIFICATE OF EKEMPTIO FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need rat be completed If the work Involved by- ABSORPTION UNIT BTU 7�SRICTNO J;SSIDBY .' -
the permit to forformed dollen (floe) or leu) /O I, e'f l �
' I cerli that in the
rformance of the work for which the AIR HANDLING UNIT CFM
permit is Issued I shall not employ any person in any manner
So as to become subject to the Workers'Compensation Laws - BOILER BTU APPg ALS DATE INSPECTORS SIGNATURE
Date m Applicant - COMPRESSOR BTU ROUGH &W067z4
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL �osiro
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER -VALIDATION
i with comp)y with such provisions w this permit shall be deem- - -
ed revoked `
\ FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION -7 FLOOR BTU
I hereby affirm that I am licensed under provralons of Chaptor 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
Ucenm Number j Lic Class��� , Q
> u
ContrxtDate IC
qZ0,Z _ K
❑ I am exempt under Sec O
• Plan check fee � G
B&P C for this reason rn
Date PERMIT ISSUING FEE $ Z
Signature TOTAL FEE- I
OWNER BUILDER DECLARATION - - RAN CHECK APPLICANT -
I hereby affirm that I am exempt from the Contractor s License 1
Low for the following reason (Section 7031 5, Business and NAME- - - - - - ,-
Professions Code)
I as owner of the property or my employees with ADDRESS _
wages as their sole compensation,will do the work and ACC T.
_ the structure is not intended or offered for sale(Section - CITY TEL NO L - T
' 7044, Business and Professions Cade) 6-7,130
1, as owner of the
- property, OWNER �V
a p rry, am exclusively contracting
' with licensed contractors to construct the project (Sec MAIL I ITEMS
tion 7044 Business and Professions Code) ADDRESS TOTAL 37- 00
CONSTRUCTION LENDING AGENCY CITY /yDN r e.ay TEL NO �p
I hereby affirm that there is a construction lending agency for �J�l� CHECK 37.00I
the performance of the work for which this permit is issued CONTRACTOR/$ ,
(Sec 3097 Civ C) _ hHANIZ .00
ADDRESS -
Lender's Name t � � • '
Lender's Address CITY - C- b TEL No SL��-�,(� G -� - - -• - OOnOnD�-UUDI 1U/ 9/9U
I certify that I have read this application and state that the LICENSE NO ATE j LIC
V 3203 I AM 9:45
above information is correct I agree to comply with all County '
ordinances and State jaws relating to building construction, - - - - - - -
and hereby authorize representatives of this County to enter
u the above-mentioned operty fw inspection purposes - -- -
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant of Applicant or�nt � -
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