HomeMy Public PortalAbout5113 SERENO DR_Mechanical__ aWORKER SCOMPENSATION of consent
784384 DPW afBB APPLICATION FOR PERMIT LIME GREEN ,
1 hereby affirm that.I neve a certificate of consent to sell Insure 764361C
or a certificate of Worker a Compensation Insurance or a certified - -I' MATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec 3800 Lab C) -
Pol o lmpeny 5xkraf Two4uVILCOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ,
Certified__copy Is hereby furnished
❑ Camfled copy re filed with the county building inspection FOR APPLICANT TO FILL IN IwF� rj'I l 5
depertinenl (PRINT OR TYPE ONLY)
aa) LOCALffY -
Dete App4cent Irl n/�A/�rf NO TYPE OF APPLIANCE OR L-OUIPMENI' FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCECROSS ST o
is aactlon need not be coin leted H the work Involved b the ABSORPTION UNIT BILI
(Th P Y ASSESSOR
MAP BOOK PAGE PARCEL
permit Is for me hundred dollars($100)or tau) AIR HANDLING UNIT CFM—
certify
FM ourscr iso m
I certify that In the performance of the work for which this permit
Ie issued I shell not employ any person In any manner iso e9 to BOILER BTU y i
become Subject to the Workers Compensation Laws - Opp
COMPRESSOR BTU
.wrwua DAM esxvu
Date AppllceM VENTILATION SYSTEM
NOTICE TO APPLICANT If after making This Certificate of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER - -'
provisions of the Labor Code you must fonhwlth comply with such FINAL .3Q
provisions or this permit shall be deemed revoked FURNACE .- FAU O j
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter B SUSPENDED UNIT
(commemmng with Section 7000)of Division 3 of the Business and HEATER WALL '
Professions Code and my license Is in full force and Shoot
a N
Lwensumber j[/ l n Lrc class -
a
Contractor Date V O
❑ I em exempt ender Sec Plan check fee �-`1 •T U
8 eP C for this reason PERMIT ISSUING FEES Q "'S�' 11�•7[I 0
1 ITEM v
°ere TOTAL FEE ;'fl(AL. 1 18 20 LU
Signature �..�...�
101-
OWNER BUIIDE LARATION _ PLAN CHECK APPLICANT CHECK 113.:13 z
I hereby affirm that I am exempt from the Contractor a License Lew NAME CHANGE - AD
the following reason (Section 7031 5 Business and Professions r
Code) ADDRESS
❑ I as owner of the property or my employees with wages
as their sole compensation will do the work and the CITY TEL NO j� �01 5/14/94
/structure is not intended or offered for sale (Section 7044 • _ O ` O•'O
Lit,(t// 6531 1 AIS v...7
BualneaS and Professions Code) OWNER
I as owner of the property am exclusively contracting MAIL p _
with licensed contractors to construct the project (Sec ADDRESS
hon 7044 Business and Profesmone Code) /
CONSTRUCTION LENDING AGENCY CfiY O yz'r�"L T
I hereby affirm that there is a construction lending agency for NRACTOR T _
the performance of the work for which this permit s issued u ^-t '
(Sac 3097 Civ C) i ' r
ADDRESS Elps
Lender a Nemo
Cardene Atltlreaa CITY TEL NO
I oertily that I have read this application and state that the above Sic su No 66ftlESS - - - - --
Information is correct I agree to comply with all County ordmanixaa
and State laws relating to building construction,and hereby authorize - - -
representatmw of this County to enter upon the above mentimad
property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE — -
BIt aNA� aR ENT TE - i