HomeMy Public PortalAbout5252 SERENO DR_Mechanical__ WORKt I haveCOMPENSATION Of consent to r 9r� APPLICATION FOR PERMIT MINE GREEN
I hxebj affirm that I have a cenlllcete cl consent to sell Insure 7B�l9ssC
or a certificate of Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3800 lab C) 1
t
Policy
No D°'"pe"y COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
CeNlied copy is hereby IumnMd
❑ Certified copy Is filed with the county bunling Inspection FOR APPLICANT TO FILL IN BUILDING
5
department (PRINT OR TYPE ONLY)
Dale I AppliamLOCALITY
110 TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERSf�ARVT
CROSS ST _
COMPENSATION INSURANCE ABSORPTION UNIT BTU
(This section need not be coraplated If the wort Involved by the MMAAP BOOK PAGE PARCEL
penult N for one hundred dollars(8100)or Neo) I AIX HANDLING UNR CFM
omimr:r rn
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
become subject to the Workers Compensation Laws
COMPRESSOR BTU 99)006 s�16
Omer/ /4 3 u°"ov"u wTa .rxtrat a eiow�rua
Appf antdq&dVENTMTION SYSTEM
NO7 E 70 APPLICANT If after making this Certlllcete o ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FKAL
provisions or this permit shall be deemed revoked I I FURNACE FAU GRAVRY
LICENSED CONTRACTORS DECLARATION FLoaR eru VAI b4linlil
I hereby affirm that I am licensed under provisions of Chapter a SUSPENDED UNR_
(commencing with Section 7000)of Division 3 of the Business and HEATER WALL
Professions Code and my license la In full force and effect
51Rb�1 lac Clave (--ao ,u er
License NuPmber.{�[7 (O O ��-
Date (0-3t-q3 IL
❑ I am exempt under sec Plan check fee • -
B aP C for this reason PERMIT ISSUING FEE $ 0
U
Dole TOTAL FEE a W
a.
Signature
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ' Z
I hereby affirm that I em exempt from the Contractor a License Law NAME
for the following reason (Section 7031 5 Business and Professions , //,�� T '
Code) ADDRESS AMA
❑ I as owner of the property or my employees with wages - � M.25as their sole compensation will do the work and the CRY TEL NO '
structure is not intended or offered for sets (Section 7061 1 ITEMS
Business and Professions Code) OWNERw�
F1I'as owner of the property em exclusively contracting -AIL TOTAL,` 122-25
With licensed,contractors to construct the project (Sec ADDRESS - Abjct
CHECK 1M•`Ci
lion 7011 Business and Professlons.Code) MLM 1rLLL
CONSTRUCTION LENDING AGENCY CRY TEL 140414-1.11Q f.0 ALYT rI�(�
I hereby affirm that there Is a construction lending agency for COffTRACTOR
the performance o1 the work for which this permit fa Issued - '
(Sec 3087 CIV C) '
ADDRESS 000D-W01 '7/A/26/93
Lender a Name CRY TEL NO _ u _ - 0917 1 A�yI 8:07
Larder a Address rr�� // _
I certify that I have reed this application and elate that the above LICENSE NO tL CUSS `—
'l
information is correct I agree to comply,with all County ordinances
and State Nwe totaling to budding construction and hereby aulnor¢e
representatives of this County to enter upon the above-mentioned _
property for Inspection put sea SEE REVERSE FOR EXPLANATORY LANGUAGE
TVP FAPPLI IT � 1'S TE - I -