HomeMy Public PortalAbout5120 SERENO DR_Mechanical__ WORKERS cAcION DECLARATION
I have - APPLICATION FOR PERMIT
I hereby affrcm that have a certificate of consent to self ,
Insure, or a certificate of Workers Compensation Insurance - HEATING - VENTILATING - AIR CONDITIONING
i�Aaa4c
or a certified copy thereof (Sec 3800 Lab C ) CE 818(REV I0/81) - - - - -Policy No Company
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/ C a
tion department Q D
(PRIM OR TYPE ONLY) ADDRESS �
Date Applicant LOCALITY �'^e;tji r
CERTIFICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
COMPENSATION INSURANCE CROSS ST 'S Gr/1I'IL�7tty
(This section need not be Completed if the wad[Involved by- ABSORPTK)N UNIT BTU-
the
TU the permit Is for one hundred dollars ($100)or less ) AIR HANDLING UNIT CFM '
I certify that In the performance of the work for which this 8"
Permit Is Issued I shall not employ any person Ino y manner
so as to become subject to the War n onjj'�w BOILER BTU APIVOVALS ATE INSPl S SIGNATURE
D.* �'D �App1 i co nt s/I COMPRESSOR BTU z �O ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Cade, you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be _
deemed revoked FURNACE FA U GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR �---
I hereby affirm that I am licensed under provisions of Chapter'? HEATER 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 y
A 6
License Nu r �� Lic Class C-Zp , V
Contract Date 4.10, OOj
❑ I am exempt under Sec ul
Plan check fee N
B BPC for this reason PERMIT ISSUING FEES Z
Date
Signature TOTAL FEE
OWNER BUILDER DECLARATION RAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ,
Low for the following reason (Section 7031 5 Business and NAME
Professions Code)
❑ I as owner of the property or my employees with ADDRESS '
wages as their sole compensation will do the work and CITY TEL NO
structure a not intended or offered for sole(Section _ 1 53. 2 A
7044 Business and Professions Code) -
❑ OWNER
I as owner of the property, am exclusively contracting / i �� _ #'s e e • • 8
with licensed contractors to construct the project (Sec ''MAIL 4710
tion 7044 Business and Professions Code) ADDRESS d /�{.r(rs� 2 e e O'5 0
CONSTRUCTION LENDING AGENCY pry T',y,J��. TEL NO 78-) 3 Q 5 v
I hereby affirm that there is a construction lending agency for ALT' i
the performance of the work for which this permit is issued CONTRACTOR L '-S ` 6. 1Ij �� , _ 0525-84
(Sec 3097 Cry C ) _
Lender's Name ADDRESS �� Z0Vj
ClrY T TEL NO
Lender s Address
STATE8 ',� LIC
_
I certify that I have read This application and state that the LICENSE NO CLASS C-` Z�
above riformohon is correct I agree to comply with all County
ordi es and State laws relating to building construction
h by authorize representatives of this County to enter - _
upo ave e o d property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
c r— 7_5,:.9V '
Signature of Applicant or Agent Date - -