HomeMy Public PortalAbout5235 SERENO DR_Mechanical__ affirm
PEN8ATION DECLARATION , D�Bi� APPLICATION FOR PERMIT UME GREEN
1 hereby em ileallf f have here a certificate of consent to self insure, �7
or a certificate o1'Worker a Compensation Insurance or a candled HEATING-VENTILATING-AIR CONDITIONING ryllll'
copy thereof(Sec 3900 Lab C)
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Carried copy is hereby lumished e ¢T
❑ Candied copy Is filed with the county building uiepectnn ' FOR APPLICANT TO FILL IN BUILDING
deperanent (PRINT OR TYPE ONLY)
Dale ApplicamLOCALITY C
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
XTJ
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS 3T
COMPENSATION INSURANCE ABSORPTION UNITBTU
(This eeetlon need not W urompletetl If the work Involved by the ASSESSOR
MAP BOOK S�Q� pAG!Eokcc PARCEL OO
permit Is for one hundred dollar.({100)or Nu) AIR HANDLING UNIT CFM
I certify that in the performance of the work for which this permit narnrcr uo
is Issued I .hell not employ any person in any manner so as to BOILER BRI b
become subject to the Workers Compensation Laws
3-WAS / COMPRESSOR BTU O
Data AppRcem VENRLATION SYSTEM ��� core savuT�
NOTICE TO APPLICANT If after making this Ceftlfica a of ROUGH
Exemption you should became subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
prowslona or this permit shell be deemed revoked / FURNACE FAU d D VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I em licensed under provisions of Chapter 9 HEATERSUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code and my license a in full force and affect
q
License Number `1 L/O�+ Lic Claes /
` $ a
Contractor %At uo LIE Data 4i- 0- � ACCT.: 8
❑ .I am exempt under sec Plan check fee mm 1Q9.90Ic
S aP C for the realm PERMIT ISSUING FEES O 1 ITEM$ U
Date TOTAL FEE D 96 �` 1Q91 +
Signature OWNER BUILDER DECLARATION PLAN CHECK APPLICANT owerIIIIZ
I hereby affirm that I am exempt from the Contractor a License Law NAME •W
for the following reason (Section 7031 5 Business and Professions (N'N1�_ryi�v rrii y�r�
Code) ADDRESS OOOD- O1 8'u{!/95
❑ I as owner of the property or my employees with wages .�L
as their sole compensation will do the work and the CRY TEL NO 211.3 1 111.W 111=LC
structure Is not intended m offered for sale (Section 7044 1'
Business and Professions Code) OWNER R u (J
❑ I as owner of the property am exclusively contracting LINL R �T
with licensed contractors to construct the project (Sec ADDRESS '
tion 7044 Business and Professions Code) r�/{L�Q 1,
CONSTRUCTION LENDING AGENCY CIN TEL NO(%t)Y 3�
I hereby affirmrman that there lea constructionwhithis
lending agency for CONTRACTOR �� LE ` 4 S JG11U �
itis performance at the work for which this perms a issued
(Sec 3097 ON C)
ADDRESSIbil
Lender a Name CITY P-k) LC TEL
Lenders Address STATE 1 fy 1� LIC )n l! n
I certrty that I have reed this application and state that the above LICENSE NO W CLASS C-20 v
mforni is correct I agree to comply,with all County ordinances ,
and State laws relabng to building constmcWn and hereby suthofae
representatives of this County to enter upon the above-mentioned
property ler mspechon purpose. SEE REVERSE FOR EXPLANATORY LANGUAGE
p
Vgo CI
S
6hl TIME OF APPGGNT OR ADEM DATE