HomeMy Public PortalAbout5080 SERENO DR_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have certificate Come of consent to self
«a6 certrfie8 coificate of pythereo Workers'800 Compensation
Cfon Insurance, 76A9e4C HEATING - VENTILATING - AIR CONDITIONING
SS p�4� ��((��TTee����,, 40.00xe DWI 9�B8,
Policy N �eCampa ni !f Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING O
hon department _ Q
(PRIM OR TYPE ONLY) ADDRESS
Dote Applicant LOCALT 2 GT
NO TYPE OF APPLIANCE OR EQUIPMENT FEE �w
.CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE - _ _ CROSS ST +
(This sectlon need not be completed If the work Involved by ABSORPTION UNIT ST u DiSTRKT NO PROCESSm BY
tha Perri is for one hundred dollars($100)or Ian) - _
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 (/
+ so as to become subject to the Workers Compensation Laws BOILER BTU A RQIAI.9 DATE INSPEcrat5 SK TUBE
Date Applicant • COMPRESSOR BTU V- - — ROUGH y(9
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you-should become subject to the Workers'
1' 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 V GRAVITY ,
++ LICENSED CONTRACTORS DECLARATION FLOOR BTU
hereby affirm that I am licensed under provisions of Chapter 9HEAtER SUSPENDED 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 Num Ltc Classes q , 6
Conhxtor
Elam exempt under Sec G
Plan check fee
W
B 8P C for this reason Date PERMIT ISSUING FEE _ Z
Signature TOTAL FEE
LqZl—
OWNER-BUILDER DECLARATION RAN CHECK APPLICANT `
I hereby affirm that I am exempt from the Contractor a License ,
Low for the following reason (Section 7031 5, Business and NAME -
Professrons Code)
I as owner of the property or my employees with • ADDRESS' C
wages as their sale compensation,will do the work and i A1.[T,a `
- - the structure rs not intended or offered for sole (Section CITY - -TEL NO ` T
7044 Business and Professions Code) OWNER /(� �i� 3307 37.00
1, os owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL 1 ITEMS
S
tion 7044, Business and Professions Code) ADDRESS �D� - �� 2 TLJTAL" J7 d0
- CONSTRUCTION LENDING AGENCY Ory MD� �,L NO
I hereby affirm that there is a construction lending agencyfor `-
the performance of the work for which this, permit Is, issued CONTRACTORWe 7 ` CK .57.00(Sec 3097, Cw C ) / , CHANGE ,[I[I
ADDRESS E _ _ ,
Lender s Name
Lenders Addren QTYS ig/_ MDA/ TEL NO uy� _/(,G 6 ♦.1-1000—_000_1 10/ 9/90
I certify that I have read this application and state that the STATE u� t40 UQASS 32N 1 AM 9%4S
above information is correct I agree to comply with all County y
ordinonces'and State jaws relating to building construction
and hereby authorize representatives of this County to enter -
u the above-mentior Percy for inspection purposes - -
AL
D SEE REVERSE FOR EXPLANATORY LANGUAGE _
Sgnalure of Appl ani or Agent e +