HomeMy Public PortalAbout5082 SERENO DR_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure or a cgrhficate of Workers' Compensation Insurance
Ar 6 certffietl copy'thereof (Sec 3BOO, Lab c ) 7eAaeAc - HEATING - VENTILATING - AIR CONDITIONING
Policy N.4 pY RSD • 200646 DPW 9/8e
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COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the ounty building inspec- ' FOR APPLICANT TO FILL IN BUILDING
hon department ADDRESS �� Q
(PRIM OR TYPE ONLY)
+ Dote LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
' (This section need not be completed R the work Involved by ABSORPTION UNIT BTU DISTRICT NO PRpQ5,5EyppBBYY � �- - A
the jsmnR Is for ono performance
dooan ({wor)or Ino) L=am
I certify that in the performance of the work for which this AIR NAt�LING 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 AswrovAls CAN INSPECTOR5 SIGNATURE
Dote Applicant COMPRESSOR BTU ROUGH r B�
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL Vo 5111 rk 57
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with compI with such provisions or this permit shall be deem- -
ed revoked FURNACE FAU GRAVITY
- LICENSED CONTRACTORS DECLARATION - FLOOR BTU
I hereby off irm that I am licensed under provisions of Chapter 9HEATERSUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code-and my license a in full force and effect
License Numb '-
s y��73�Lic Class +�" 0
u
Contractor 660 ZZIY
❑ 1 am exempt under Sec G
Plan check fee
B 8P C for this reason w
Dote PERMIT ISSUING FEE $ 3 — W
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ►
Law for the following reason (Section 7031 5, Business and NAME _ _ l
Professions Code)
❑ 1, as owner of the property, or my employees with ADDRESS _
wages as their sole compensation will do the work and ��Ts a
the structure is not intended or offered for sale (Section CITY TEL NO t
7044, Business and Professions Code) OWNER KV .S+y�� 3307 37.00❑ 1, as owner of the property am exclusively contracting
with licensed contractors to construct the Project (Sec- MAIL 1 ITEMS
tion 7044 Business and Professions Code) ADDRESS z.
CONSTRUCTION LENDING AGENCY CITY O� 2' TEL tJ0 ( TOTAL 37- 00
I hereby affirm that there is a construction lending agency for
CHEGY 37,00
the performance of the work for which this perms is issued CONTRALTOCHANE .131]
(Sec 3097, Gv C) G 7/�
ADDRESS / 7,1
Lender a Name _ v ••r*� /'r�� �r
❑TY S, TEL NO
Lenders Address �J 1 .• - _ DODD—DWI 10/ 990
I certify that I have read this appbcotionand state that the LICENSE NO CLASS G 42 3205 1 AN 9:48
above Information is correct I agree to comply with all County -
ordinances and State laws relating to building construction, - -
and hereby authorize representatives of this County to enter
upa the above-mention operty for inspection purposes - -
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of APpilcant or gent ( ate' -
®s