HomeMy Public PortalAbout5242 SERENO DR_Mechanical__ WORMER S COMPENSATION DECLARATION 204W8 DPW 9199 r '
I hereby affirm that I have a certificate of consent to self insure 76A364C APPLICATION FOR PERMIT LIME GREEN �
or a certificate of Worker s Compensation Insurance or a certified _ HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec 3800 Lab C)
P011cy No -Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
Cerllhed copy/whereby"aped
❑
❑ Ce M d coP1'Is filed with the county building inspection FOR APPLICANT TO FILL IN BUIt.aNG ,
aepanmem (PRINT OR TYPE ONLY) 0
Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY-T
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS Si OS
(This section need not be completed M the work Involved by the ABSORPTION UNIT BTUASSIESSOR
MAP BOOK PAGE - PARCEL
permit in for one hundred dollar($100)or less) AIR HANDLING UNIT CFM oerwcr ra egp�er ,
I certify that in the performance of the work for which this permit
is Issued I shall not employ any person in any manner so as to BOILER BTU p
become subject to the Workers Compensation Laws COMPRESSOR BTU
QQO
DApplicant VENTILATION SYSTEM
NOTT/i rrvnwus �J
wrc Nerecroa aaaunae
TO PPLICANT If after making this Certificate of ROUGH Z
Exemption you should become subject to the Workers Compensation EVAPORATIVE
provisions of the Labor Code you must forthwith comply with such COOLER FINAL
provisions or this permit shell be deemed revoked FURNACE FAU V GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDA ON
1 hereby affirm that I em licensed under provisions of Chapter B , SUSPENDED UNR
(commencing with Section 7000) of Division 3 of the Business and HEATER WALL
Professions Code and my license is In full force and effect O��'
r pp// �^t --O //I� '']� q� 1 -
License Number,1 q(2 9- - Lic Clan C-X .�
,L"� �`p ap
Contractor x fo-30 U
❑
- I am exempt under sec Plan check fee
B sP C for this reason PERMIT ISSUING FEES U
Date TOTAL FEE Wil
Signature N
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractors License Law NAME ►
for the following reason (Section 7031 8 Business and Professions G
Code) I ADDRESS
❑ I as owner of the property or my employees with wages _ _ _ ACCTJ _
as their sole compensation will do the work and the CITY TEL NO - - �Y]
structure is not intended or offered for sale (Section 7044 '�`�� MC 12.23
Business and Proleeelons Code) OWNER �� AA ! ' _ ' 1 I I C7S
❑ I as owner of the property am exclusively contracting MAIL t'0� _ TOTAL_ :122_
with licensed contractors to construct the project (Sec ADDRESS � ` LN _ 25
ton 7044 Business and Profeamons Code)
CONSTRUCTION LENDING AGENCY CITY F TEL - -- - _ ���+LLU1Aa�u�s a •�`5
I hereby affirm that there is a construction lending agency for CONTRACTOR tiTvy7lgL �(�
the performance of the work for which this permit le issued } {� - _ - -
(Sec 3097 CN C) w , _ ) .. .. p I
ADDRESS - `U _ wVyl,ryyl __7/26/73`
Lenders Name
CITY TEL fa _ -- - - - " - 0921 1Taft 8:09
Lender a Address STATE
I certify that I have reed this application and state that the above uCFxsE rq CLA33
mformaluen iscorrect I agree to comply with all County Ofdmmncae
and State laws relating to budding construcifori,and hereby authorae
representatives of this County to enter upon the above-mentioned
property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
'7 Z3 13
r41 aE MIT ORA m TE ' ,