HomeMy Public PortalAbout5233 SERENO DR_Mechanical__ WORKER S COMPENSATION DECLARATION aj� APPLICATION FOR PERMIT UME GREEN
I hereby affirm that 1 have aveaa cacsnlllcateof consent to self insure �7
or a certificate of Worker a Compensation Insurance or a certified . HEATING-VENTILATING-AIR CONDITIONING �ILIII
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 furnished '
❑ Cer0lkd copy is Bled with the county buildup Inspection FOR APPLICANT TO FILL IN BUILDING
NG
tlepertmem (PRINT OR TYPE ONLY)
SS
Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY L`-'
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
• COMPENSATION INSURANCE CRO58 ST
ABSORPTION UNITBTU
(This uetlln nsstl not be completed N the work Involved by the ASSEMAP BOOK PAGE61PARCEL O
permit Is for one hundred dollars($100)or tau I AIR HANDLING UNIT CFM
asrnx:r ao ano�seBo e.
I certify that in the performance of the work for which this permit �
is issued I shall not employ any person In any manner 6o as to BOILER BTU
become subjltcl to the Workers Compensation Lowe
COMPRESSOR BTU (a' do
DataJLIL�LJ -�_ADDIbant h(�A�1A�I` .wrrnwaa won enar£cmmesmuiune
i - - VENi1LAT1ON SYSTEM
NOTICE TO APPLICANT It after—making this Certl llcate of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER FINAL
provisions of the Labor Code you must forthwith comply with such
provisions or this permit shell be deemed revoked FURNACE !C FAL // `
LICENSED CONTRACTORS DECLARATION FLOOR BiIJ Z VALIDATION
I hereby affirm that I am licensed under provisions of Chapter a HEATER SUSPENDED UNR_
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Coda and my license Is In lull force and effect
License Number '711"SW Lk Caul 8AC/.T
Ccnuenor " W Aug LE _ nw. 1 r.D 010. �7W 118.30
CL
ElI am exempt under sec 2 Plan check fee * 1 ITE rrn IJ `VVIt
B LIP C to this reason PERMIT ISSUING FEE O TOTAL I 1$ 313 O
CHECK F
SignaturePLANCHECK APPLICANT Oma TOTAL FEE .36 118.00 OWE y
S
OWNER BUILDER DECLARATION rw�r�L�r1r1 �-:ef ee ?
1 hereby affirm that I em exempt from the Contractor a License Law NAME , OOOU-0001 8/307 J
for the following reason (Section 7031 5 Business and Professions
Code) ,SSS 2112 1 AM11422
❑ I as owner of the property or my employees with wages
as their sola compensation will do the work and the CITY TEL NO
structure Is not Intended or offered for sale (Section 7044 ,`
Business and Proleselons Code) OWNER P"1 E],j
❑ 1 as owner of the property am exclusivelycontracting tingMAIL
��` ,
with licensed contractors to construct the protect Sec ADDI C 1 %T
lion 7044 Business and Professions Code) CITYG` T TEL �a%j �q���
CONSTRUCTION LENDING AGENCY a
N hereby affirm that there is a constructionhithis
lending agency for CONTRACTOR p yl T 4
the performance of the work for which ihie permit s Iaeuetl OI 1 J
(Sec 3087 Cry C) p /� 1 f�� � �^ (�
ADDRESS Lt� G
Lender a Name
CITY
G -t o YA C♦ TEL NO %
Lander
—
_
a Address STATE - LIC
1 certify that I have read this application and state that the above LICENSE NO CLASS —
mfonnation is correct I agree to comply with all County ormnarim
and State laws raseng to building construction and hereby authorize
representatives of this County to enter upon the above mentioned
property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE