HomeMy Public PortalAbout5258 SERENO DR_Mechanical__ ION
I affirm
that I have
a certificate
of consent to erg APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to sell insure
or a certiicate`ol Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Elec 38001eb C)
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ C.Ufi d copy is hereby funuehed
❑ Cemhetl copy m filed with the county,building Inspec xut FOR APPLICANT TO FILL IN BUILDING 5 5
OePartmMt (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY -{-'
fq TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST _
ABSORPTION UNIT.BTU ASSESSOR
(TNIe Action need not be completed If Me work Involved by the MAP BOOK PAGE PARCEL
permit la for one hundred dollars($100)or Nu) '
reoccasso
I certify that In the performance of the work for which this permit AIR HANDIJNG UNIT CFM ororwcr IA BY
is Issued I Shell not employ any person in any manner so as to BOILER Bit
become subjec to he CWorkers Compensation Lem �y D�
j\3 COMPRESSOR BRQl `-' d ��a,�v p,r� rmcnB enrunrE
Dale Applicant VENTILATION SYSTEM
` NOTICE TO APPLICANT If after making this Certificate of ROUGH
'Exemption you should become subject to the Workers Compeneatian EVAPORATIVE GOOIER
provisions of the Labor Code you must forthwith comply with Such FINAL
provisions or this permit shell be deemed fevoketlFURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR aTu VALIDATION
I hereby affirm that I am licensed under provisions of Chapter a HEATERSUSPENDED UNfT_
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code and my license is in full force and effect
�'77 //��
License Number Llc Class�V>y
Centractpr�,Roc=rr�.. to-3 i -�3 _
a
—„ e
❑
- I am exempt under Sec Plan Check fee
B SPC for this reason PERMIT ISSUING FEE$,04&p' D!A1 - O
- �3 12i.�5 U
Date TOTAL FEE ,-1 1 ITEMS d
Signature co
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT TOTAL. 122 .25Z
1 hereby affirm that I am exempt from the Contractor a License Lew NAME I.nG� 122s 2c s
for the following reason (Section 7031 6 Business and Professions LRE
Code) ADDRESS CHANGE .W
❑ I as owner of the property or my employees with wages P
ae their 3010 compensation will do the work and the CRY TEL NO ,
Structure is not intended or offered for sale (Section 7044 DOW
Rumness and Professions Code) OWNEFi DOW—DWI 7/26/93
F1e
I as owner of the property em exclusively contracting AWL Te PE TALN0915 1 � 807
with licensed contractors to construct the project (Sac ADDRESS
tion 7044 Business and Professions Code)
- CONSTRUCTION LENDING AGENCY CRY TEL NO 14 _
I hereby affirm that there Is a construction lending agency for ACTOR '
the performance of the work for which this permit Is issued 11
(Sec 3087 Clv C) T
ADDRESS
Lenders Name /1
CITY `T tv_"IO TEL NOqq� _
Lander a Address (�
I certify that I have read this application and state that the above L�iCAE NO L, CLASS
information is correct I agree to comply with all Counly orp"nu cee
and State lave relating to building conStruggn,and hereby authorize ,
representatives of this County to enter upon the above�mentwrred r
property for inspection purposes rx SEE REVERSE FOR EXPLANATORY LANGUAGE
OR AOFM ` 2