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Home My Public Portal About5100-5102-02 1/2 SERENO DR_Mechanical__ WORKRS COAIPI NSATION DECLARATION 76A364C I hereby affirm that I hav, a certificate of consent to self CE BIB (2 BD) APPLICATION FOR PERMIT insure or a certificate of Workcrn Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING a certified copy thereof(Sec 3800 Lab C ) - Policy No Com pan) Certified copy Is hucby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY - Certified copy Is filed with the,county budding inspection FOR APPLICANT TO FILL IN BUILDING - department ADDRESS Date Applicant (PRINT OR TYPE ONLY) t LOCALITY C1 RTII ICATI Of h%P\IPTION I ROM RORKLRS NO TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST y his Section neCd not be completed If the work involved ABSORPTION UNIT BTU CROSS ST 0 the permit IS for one hundred dollars (SI00) or less) DISTRICT No �// C,ocES• Day U I "rtify that in the performance of the work for which this AIR HANDLING UNIT CFM �V t permit r; issued I shall not em plus any person In any manna p O so as to become subject lis the Workers Compensation Laws BOILER BTU VVVC APPROVALS DATEINSPECTOR S SIGNATURE yIyL �late/��Z COMPRESSOR BTU ROUGH /!! N RKITICL TO APPI ICANT If after making thLsiertificale of VENTILATION SYSTEM FINAL �� Z Exemption you should become subject to the Workers �Compensatmn provisions of the Labor Code you must forth EVAPORATIVE COOLER 11 VALIDATIO With Comply with Such provisions or this permit shall be `v' deemed res nked FURNACE FAU_/C— GRAVITY — I IC}NSFD CONTRACTORS DELI AR ATION FLOOR 6TU /I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT 9 (commencing wnh Section 7000) of Dwismn 3 of the Bust WALL nus and ProfesVons Codi, and my license Is In full force and ef4e[ aa rr-''y y License Number�_8b IIJy Luc Class�,�r✓ G+ntmctor(rfJ�W_7_�_�� Date_IO_L� Vo F1I am exempt from the licensing requirements as I am a licensed architect or a registered professional engmcer Plan check fee 25%of above acting inmy professional capacity (Section 7051 Bus PERMIT ISSUING FEE S mess andd Yro4ssions Code) Ls or Reg No Date TOTAL FEE - HONU OWNER BUILDFR DLCLARATION PLAN CHEC7APPLICANT I hereby affirm that 1 am ctempt from the Contractor's NAME License Law for the followmg reason (Section 7031 5 Bust ness and Professions Code) ADDRESSI as owner of the propLrty wdl do the work and the CITYTEL NO structure is not Intended or offered for Sale (Section 7044 Busmess and Professions Codc) ❑ OWNER 1 as owner of the property am excl usrvely contractingwith licensed contractors to construct the project ADDRESS (Session 7044 Busmess and PlOfeSSIOnS Code) CONSTRUCTION LLNDIN(, AGLNCY CITY CYA !ttjf TEL NO 2!_] -, Q �2438A I hereby affirm that there is a onstTuction lending agency JJ/r'''�' I�r I J�/- for the performance of the work for whish this permit Is CONTRACTOR issued(Sec 3097 Cry C ) -•—�—— - 4 Lender s home ADDRESS/{r/,S _4,, '} I{�� 2 1 7 0 0 Lenders AddressCITY6,1*V GwNT�Y TEL NO -�"�-3570 ,� 700 I certify that I have read this application and slate that the STATEt'p LIC /��36 abuse,information IS current I agree to comply ssith all County LICENSE NO 0 D/ CLASS tr I 002 8 0 ordinances and State laws regulating Heating Venal Ring and 1 - + Air Cinidmnnmg and hereby authonre represenlatoes of this SLI RLVLRSL EOR CNPLANATORt LANGUAGE Counq to enter upon the above notntioned property for inspection p rp^nes p �r /`Slgna[ure ut erm [ ee 1WORKFRS'COMPINSA f10NDECLARATION 76A364C 1 hereAPPLICATION FOR PERMIT by a Orm that 1 hale a certificate of consent [n self CE 818 (2 80) msurC or a c,rtiflcate of Workers Compensation Insurance or HEATING-VENTILATING- CONDITIONING a certified Lopy thereof(Sec 3800 Lab C ) Pvticy-No Company COUNTY OF L S SANG BUILDING AND SAFETY Certified cape Is hereby furnished Certified Lopy is filed with the county building Inspection BUILDINGt / department FOR APPLICANT TO FILL IN ADDRESS S�Da �FA.Sr/off Dale Applicant (PRINT OR TYPE ONLY) ' LOCALITY CLRTII KATE OI EXEMPTION PROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE NEAREST CROSS ST d lits seCtjon Reed not be completed If the Rork Involved -` ABSORPTION UNIT BTU O by the permit Is for one hundred dollars (5100) or less) DISTRICT W aacFssEt ev U I earl ity that in the perform ailnL of the work fur which this AIR HANDLING UNIT CFM S� S permit Is Issued 1 shall not employ any person in any manner (/ O so as to become subject to the WlirkLrs Compensation Laws BOILER BTU U APPROVALS DATE ' iNSi'ECTOR S SIGNATURE Dale�D=Z�=Applicant_ COMPRESSOR BTU W ROUGH permit TO APPI(CANT If after making this Certificate of VENTILATION SYSTEM FINAL 7-1 Z Exemption )ou should become subject to the Workers Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION ' ith comply with such provisions or-[ha permit shall be deemed revoked FURNACE FAU— GRAVITY_ LICENSED CONTRACTORS DEC[ARATION LOOR BTU 1 herebv affirm that 1 am licensed under provtsions of Chapter HEATER SUSPENDED UNIT 71 9 (LOmmenc ng with SLLtwn 7000) of Doision 3 of the Bust WALL nus and Professions Code and my hLLnse is In full forci, and effect Llctnse NumbbLr 3-!0917 Lac Class 3 , Contractor n/ tpy/0f<_ Dale_/b_/-tt0 1 am exempt from the licensing requirements as I am a hcensLd architect or a registered professional engineer Plan Check fee 25%of above acting in my professional capacity (Section 7051 Bus PERMIT ISSUING FEE $ meas and Professions Code) Lie or Reg No Dat, TOTAL FEE a7 -- HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ` I hereby Affirm that 1 am Lxs.mpt from the Contractors NAME License Law for the following reason (Section 7031 5 Bust — ness and Professions Code) ADDRESS I as owner of the property will do the work and the StruLturL Is not intended or offered for sale (Section CITY TEL NO 7044 Business and Professions Code) I ❑ OWNER 1 as aw nLr of the property am exclusrvLly contraLting �✓ /� ` with LLensed Lontra,tors to conatruLt the project MAIL q n (SCLtlon 7044 Buian"s and Professions Code) ADDRESS SC 3b �46Qt4 („y :9 2 4 3.7 A CITY TEL NO -�/q CONSTRUCTION LENDING AGENCY $/�t/bd5 O -tSTf_O �j • •�• • 4 1 hereby affirm that there Is a construction lending agency for the performance of the work for whish This puma is CONTRACTOR Af Sp�V b tuned (Sec 3097 Ci, C ) •--' •--µ '� 2,0*0 27 00 Landes s Name ADDRESS (�L i Lender s Address /�� /�r�� 2 7,O �c�5 CITY�NL/A� /�jsV /EL NO 1-3 20 1 certify that I hose rLad this application and Stan, that the STATE TT�V LIC 12'_8abo%L Intnrmatmn Is LurrLLt 1 agreL w comply with all Coun[y tICENSE NO � CLASS � ordinances and State laws regulating HLatmg ventilating and Air Conditioning,and hLreby authorve rep1C5LMatoCS of this SEE REVERSE I OR EXPLANATORY LANGUAGE Lounh to entLr upon the abuse mentionLd property for unpectut p rpos s o Sig iature of Permittee Date