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Home My Public Portal About5211 SERENO DR_Mechanical__ 1 • WORRPENSATIONDECUIRATIDN 7e CDPWe,BB APPLICATION FOR PERMIT LIME GREEN I hereby affirm ChettIhave have a certificate of consent to Bell Insure or a cytificate of Worker a Compensation Insurance or a certified HEATING -VENTILATING-AIR CONDITIONING copy thereof(Sec 3900 Lab C) j , Poliry No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ❑ Carolled copy re hereby tum shed ❑ =copy Is filed with the county bulldog Inspection FOR A(PP� LPCRANE oOLFILL IN BUILDING ADDRESS Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT ' ' FEE LOCALITY ' CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST COMPENSATION INSURANCECROSS ST (This section need not M putted If the work Involved by iM coins ABSORPTION UNIT BTU ASSESSOR p 3 PARCEL permit Is for one hundred dollen(111111100) BOOK PAGO�a OD)or lap) NR HANDLING UNIT CFM � ��r rp modem Or 1 certify that in the performance of the work for which this permlt is issued I aceto not Worley any person In any manner so as to BOILER BTU become subject to the Workers Compensation Lewy COMPRESSOR BTU AI•mnVAta run .�roas eruunxs Data Applicem VENTILATION SYSTEM NOTICE TO APPLICANT If alter making thio Certificate of ROUGH Exemption you should become subject to the Workers Compensation EVAPORATIVE GOOIER provisions of the Labor Code you mutt forthwith comply with such FINAL provisions or this permit Shell be deemed revoked FURNACE FAU_ LICENSED CONTRACTORS DECLARATION FLOORBTU VALIDATION I hereby affirm that I em licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT— Professions UNR_ (commencing with Section 7000)of Division 3 of the Business fundWALL Professions Code and my license a In lull force and effect License Number Loc Close �B✓��• } Caniraclor Data ❑ I am exempt under Sec Plan Check fee B 8P C for this reason PERMIT ISSUING FEE �p Den TOTAL FEE a Signature N OWNER BUILDER DECLARATION PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractor a License Lew E Witm; A.v/ for the following reason (Section 7031 5 Business and Professions /7r�N I as owner of the property or my employees with wages ADDRESS ICW/ Q!�o Atli YlC11 .T as their sole compensation will do the work and the CT' TEL NO�/ p/„/ �/O structure is not intended or offered for sale(Section 7046 /Gb, UU 1 ITEIT:' Business and Protesmons Code) ER F-1I as owner of the property am exclusively contracting .011MMALL C 701 AL 102 00 with licensed contractors to construct the project (Sac ADDRESS tion 7044 Buatnesa and Professions Code) CONSTRUCTION LENDING AGENCY CRY S/YAr LT' TEL NO s'"'°e- = r.W03E •ISI•` I hereby athat (here lee construction this lending agency for IShe ecp3097r men Civ C j ff the work for which this permit Is Issued CONTRACTOR vt , N!/n/B GNAN LAU 0�1— J1 /`5rS Lenders Nemo ADDRESS _ �T _ _ `I� Lendera Address .1 Y/ ✓g' N� Ae STA TEL NO' y41 f i A I 7 STATE LIC I certify that I have reed this application and state that the above LICENSE NO CLASS informatlan is correct I agree to comply with all County ordinances and State laws relabng to bustling construction,and hereby authorize _ reprea intahv a of this Court to e r upon the above-mentioned V.Prope Unsp101 pur SEE REVERSE FOR EXPLANATORY LANGUAGE OR )AA - WORKER I have a ENSATION DECLARATION 7000IBDPW 9189 APPLICATION FOR PERMITLIME GREEN , 76A'M/C I hereby affirm that I have a certificate of consent to Bell insure or a certific}te of Worker a Compensation Insurance or •certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec 3800 Lab C) ' Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ❑ Certified copy is hereby tumiehed ❑ CNIAW copy is Bled with the county building Inspection FOR APPLICANT TO FILL IN BAR sus - department (PRINT OR TYPE ONLY) LOCALRY Date Applicant NO TYPE OF APPLIANCE OR EOUIPMEN7 FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS CROSS Si COMPENSATION INSURANCE ABSORPTION UNrr,BTU y p (This section Mad not be completed If the work Involved by the =F—B'O'OK ,Jp 'AGOG PARCEL permit Is for one hundred dollars(8100)or leu) AIR HANDLING UNITCFM a ,-r tp I certify that to the performance of the work for which this permit is issued I shall not employ any person In any manner so as, to BOILER BTL become subject to the Workers Compensation Laws -5—�O COMPRESSOR BTU AIPIOVAIa wre f18.�Clae a aos�nne Delo Applicant VENTILATION SYSTEM 'if 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 forthwith comply with such FINAL provisions or this permit shall be deemed revoked FURNACE FAU_OMVRY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION_ I hereby affirm that I em licensed under provisions of Chapter 9 '7 SUSPENDED UNR_ _ (commencing with Section 7000)of Division 3 of the Business and OS HEATER Professions Code and my license Is In full force and effect WCTA .i License Number - LIc Clan 4vb' p , Ali1 ITEh: > Contractor Date I r TOT& 77 - 1 70 $ Plan check fee 77 _ I am exempt under Sec CHECK HECK „'' I= B aP C for this reason PERMIT ISSUING FEE t p _ '_4ANGE 8 0 DateTOTAL FEE Jf TAT W CL Signature PLAN CHECK APPLICANT , , 21 1/9't w OWNER BUILDER DECLARATION 1 � 5�$� z 1 hereby affirm that I am exempt from the Contractor a License Law NAME for the following reason(Section 7031 5 Business and Professions Code) ADDRESS ❑ I as owner of the property or my employees with wages as their sole compensation will do the work and the CRY TEL NO structure is not Intended or offered for sale(Section 7014 Business and Professions Code) OWNER ❑ I as owner of the property am exclusively contracting With licensed contractors to construct the MAIL project (Sec ADORE ll,-2 tion 7044 Business and Professions Code) L NO CONSTRl1CTIDN LENDING AGENCY hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is Issued - - - - (Sec 3097 Civ C) ADDRESS Lender a Name CRY TEL NO Lenders Address STATE LIC I certify that I have reed this application and state that the above LICENSE NO CLASS - informetron is W ect I agree to corn iy with all County orc mencee and State laws retailing to building construction thereby auth representatives of this County to enter Y operty for inspection urposes SEE REVERSE FOR EXPLANATORY LANGUAGE lie 1 APP