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Home My Public Portal About5246 SERENO DR_Mechanical__ WORKCOMPENSATION DECLARATION 7 DPW s/� APPLICATION FOR PERMIT LIME GREEN I hereby affirm thatt I havehave a certllicate of consent to self Insure or a certificate gf Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec 3800 Lab C) Policy No Cornpany COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV ❑ Certified copy m hereby furnished ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN Bu1LrnNG department (PRINT OR TYPE ONLY) ADDREN DateLOCALITY T C` Applicant NO TYPE OF APPLIANCE OR EOl11PMEM FEE � CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST COMPENSATION INSURANCE CROSS ST (This section need not be completed If the wort Involved by the ABSORPTION UNIT,BNASSESSOR MAP BOOK PAGE PARCEL permit Is for orm hundred dollen(0100)m lese) AIR HANDLING UNIT CFM ��rp pS�ss£c ay I certify that In the performance of the work for Which this permit Is Issued I shell not employ any person In any manner so as to BOILER BTU p become subject to the Workers Compensation Laws QO �O COMPRESSOR BTUL19 � � o/,h wescCraaemon� Dani7�(X:3 3 Applicant VENTILATION SYSTEM NOTICE TO APPLICANT It after making this Certificate of ROUGH Exemption you should become Subject to the Worker Compensation EVAPORATIVE COOLER provisions of the Labor Code you must forthwith comply with such FINAL provisions or this permit shell be deemed revoked FURNACE FAU V RRVITY LICENSED CONTRACTORS DECLARATION I FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter B HEATER SUSPENDED UNIT_ (commencing with Section 7000) of Division 3 of the Business and WALL Professions Coda and my license is In full force and effect Z L;csmxl Number 5 tq G4& Uc Clave C-01�O ,.} l • Ll- Canvactor Date 0 Plan check fee 0 ❑ I em exempt under Sao Q B AP C for ows reason PERMIT ISSUING FEES G Q 0 Dere TOTAL FEEW Signature -A22 CL PLAN CHECK APPLICANT fn OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor s License Lew NAME , for the following reason (Section 7031 5 Business and Professions v Code) ADDRESS ACCTS i ❑ I as owner of the property or my employees with wages as their sole compensation will do the work and the CRY TEL NO sI� itcs� structure is not Intended or offered for sale (Section 7044 1 ITEMS Business and Professions Code) OWNER ❑ I as owner of the property am exclusively contracting MAIL 5 A �� TOTAL 122-'2-05 with licensed contractors to construct the project (Sec ADDRESS WA _ S tion 704� 25 COONSSTRUCTIONess and LEf Professions NG AGENSCY CITY rC IOL - TEL NO y _({ ��` ,00 I hereby affirm that there Isa construction lending agency for /' 4fl' the performance of the work for which this permit IS Issued CONTRACTOR(Sac 3087 Civ C d" �� d' 1(Z r...o/J v ,---- ) ADDRESS6 GOOD-0401 7/26193 Lender a Nemo CRY r� TEL NO IE;qql0920 1 AM E:106 Lender a Address nn / I certify that I have read this application and State that the above LID NE SE NO [_` CUSS C—ab Is correct I agree to comply with all County ordmences and State laws relating to building construction and hereby authorize representatives of this County to enter upon the above mentioned property for inspection purpoeas SEE REVERSE FOR EXPLANATORY LANGUAGE �Yi :!