HomeMy Public PortalAbout5250 SERENO DR_Mechanical__ WORKER I haveCOMPENSATION of consent
to DPW 9189 APPLICATION FOR PERMIT `IME GREEN
I hereby ellnm IAei I have a certilicete of coneenl to self Insure ]alpBNC
or a certificate of Worker a Compensation Insurance or a certified HEATING-VENTILATING -AIR CONDITIONING
Copy thereof(Seo 3800 Lab C)
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ . , CertrfWd copy Is hereby furnL~ '
❑ coq to need with the county building Inspection FOR (PRINTOR TYYPPEANT TONLYY))ILL IN CESS
r le G
- Dale Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS CRO SSTST
COMPENSATION INSURANCE ABSORPTION UNIT BTU -
(This section need not be completed ti the work Involved by the MMAAPP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)w leu) AIR HANDLING UNITCFM owrRcr w moccesm an
I certify ue I In the t performance an of the work for which the pastil
is Issued I shell not employ any person In any manner u as to BOILER BTU
become subject to the Workers Compensation Laws •NJ4
COMPRESSOR BTU
O�I .Pvav+sae Dore rmrecma a aorutuRe
Date 7 3 Applicant VENTILATION SYSTEM
NOTICE tO A PLICANT If after making this Certificate of ROUGH
Exemption you should become subject to the Workers CompensationEVAPORATIVECOOLER
provisions of the Labor Code you must forthwith comply with such _ FINAL
provisions or this permit shell be deemed revoked FURNACE FAU ORAVITV - VALIDA ON
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I em licensed under provisions of Chapter 9 HEAer SUSPENDED - UNIT_
(commencing with Section 7000)of Division 3 of the Business andWALL ,
Professions Code'and
Qmy license is In full force and effect
License Number • `� as L. Class C-go O O ,
(J (� �,p ► 0-
Con lrattofl�,x QatAJO.MN3[�Date t ' 10-31-R3 '
❑ I am exempt untler Sac Plan Check fee -
2
B aP C for sans reeeon PERMIT ISSUING FEE0
Date TOTAL FEE ,l tiV,t
Signature - (L
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ' Z
I hereby affirm that I am exempt from the Contractor a License Law NAME ►
for the following reason (Section 7031 B Business and Professions C
Code) ADDRESS ACCT AT
❑ I as owner of the property or my employees with wages - -�t��
as their sole compensation will do the work and the CRY TEL NO 3 122.25
structure Is not intended or offered for sale (Section 7044
Business entl Professions Code) OWNER -JALALAT ' 1 I1 u i0
E] I as owner of the property em exclusively contracting MAILTOTAL '122.25
with licensed contractors to construct the project (Sec ADDRESS u� + '.r
tion 7044,Business and Professions Code) CITY
TEL
122.25
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there Is a construction lending a�ency for CONTRACTOR d' ►
,the performance of the work for which this permit s Issued Lig i el
(Sec 3097 Ch, C) - -
AODfE� ODS-0001 7/26/93
Laotian a Name
CRY G- rip _AM
Cy-( TEL N / - 0919 1 8:08
Landes a Address STATE INC
I certify that I have read this application and state that the above LICENSE NO CUSS
intormeUm is correct I agree to comply with all County ordmancea _ _, _ _
and State laws relating to building construction and hereby aulhonze
representatives of this County to enter upon the above-mentioned
pro any for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 4 _
R
AGIEWM�