HomeMy Public PortalAbout5111 SERENO DR_Mechanical__ Wt that I have a certificate
DECLARATION 76304DPW 9/e0 APPLICATION FOR PERMIT UME GREEN
I hereby ellltm thel I have a certificate of consent to Bell Insure 7�'MIC
or a certificate of Workpr a Compensation Insurance or a certified } EATING-VENTILATING-AIR CONDITIONING I I
copy thereof IS 3900 Lab C) LI
UI'd 1/'10 Donnpany 2 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
6d Certified copy M hereby lumlahed
❑ CertI11W copy le filed with the county building Impaction FOR APPLICANT TO FILL IN BUILDING
tlepnrtment (PRINT OR TYPE ONLY) ADDRESS
�y ,(,� LOCALRY
Dale_� AppllcemLA"r NO rypE OF APPLIANCE OR EQUIPMENT FEE
CE-RTIFICAT'E_OF EXEMPTION FROM WORKERS NEAREST
i COMPENSATION INSURANCE + I CROSS ST
(ThisABSORPTION UNIT BN
perm t Is I n need not be dollars
0 for work Involved by the , MMAP BOOK PAGE �� PARCEL O�
permit la for one hundred tlollan(1100)or Mw) AIR HANDLING UNIT CFM
WfeiCr aO VHOCEa®ev
I certify that In the performance of the work for which This Dermll
Is issued I shall not employ any person In any manner so as to BOILER BTU O
become subject to the Workers Compensation Lawn �QS
COMPRESSOR BTU
Date ApplicantrPvravus oATe w9H:roa seidunge
VENTILATION SYSTEM
NOTICE TO APPLICANT If alter making this Certificate of ROUGH
Exemption you should become subject to the Workers Compensation
provisions of the Labor Code you must forthwith comply with such ���TTVE COOLER FINAL
provisions or this permit shall be deemed revoked FURNACE FAU V GRAVITY
-
it LICENSED CONTRACTORS DECLARATION FLOOR BTU dG /o VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9, SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and NEATER WALL
Professions Code and my license Is in full force and efl'ed
r LIc 2
License Number Class i3- E
D ACCT.r .a
Contractor Date x303 119.558
❑ I am exempt under Sec Plan Check fee
2
B aP C for this reason PERMIT ISSUING FEES 2 k i-5� O
Dace TOTAL FEE W
Signature d � n'
O ER BUILDER D CIARATION PLAN CHECK APPLICANT 1 ITEhi5 2
I hereby affirm that I em exempt from the Contractor a License Lew NAME ,
for the following reason (Section 7031 S Business and Professions TOTAL 119 - 55
Code) ADDRESS
I as owner of the property or my employees with wages CHECK 119.x]5
as their sole compensation will do the work and the CRY TEL NO CHANGE .00
structure Is not intended or offered for sale(Section 7044
Business and Professions Code) OWNER
❑ a
I as owner of the properly em exclusively contracting MAL 0000'0001 6/27/95
with licensed contractors to construct the project (Sec ADDRESS
Tien 7044 Business and Professions Code) CCITYr 1056 1 AM 8e4E
CONSTRUCTION LENDING AGENCY TEL NO J'
I hereby affirm that there Is a construction lending aancy for ACTOR ,
the performance of the work for which this permit 4e issued -
(Sec 3097 Cw C) QQ
Lender s Name � i�
TEL NO -
Lender a Address STATE LIC -
I certify that I have read this application and stale that the above LICENSE NO CLASS
mfonnalmn u correct I agree to comply wrth all County oldmattcas -and State Incas relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes + -
Q � SEE REVERSE FOR EXPLANATORY LANGUAGE
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