HomeMy Public PortalAbout5260 SERENO DR_Mechanical__ WORKER I have a certificate of
�NejM APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a cerllhcele of consent to self Insure 764381C
or a certificate of Worker a Compensation Insurance or a certified HEATING•VENTILATING •AIR CONDITIONING
copy thereof(Sac 3BOO Lab C)
0 No Common' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
Certified copy Is hereby furnished
❑ Csrrdied copy
Is Bled with the county building Inspection - FOR APPLICANT TO FILL IN BUIL01N0
department (PRINT OR TYPE ONLY) ADD RE59
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Date AppApplicantLOCALITY
anl NO TYPE OF APPLIANCE OR EQUIPMENT FEE ` I '
CERTlRCATE OF EXEMPTION FROM WORKERS NFaREBT
COMPENSATION INSURANCE CR059�
ABSORPTION UNIT BTU
perms section naafi riotpermitor ond completed It thewart Involved by the ASSESSOK PAGE PARCFI
permit Is for hundred 1! or 100) lees) AlR HANDLING UNIT CFM '
omrwcr rq PIIpcEea®
I certity that In the performance of the work for which this permit m,
is Issued I shall not employ any person In any manner so as to BOILER BTU
become subject to the Workers Compensation Laws �1pd
COMPRESSOR BTUzis000
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Date Applicant VENTVENTILATIONVTILATN SYSTEM
NOTICE OAP LICANT If alter making tMe Cerbhcete of ROIX3N
Exemption you shouts become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed ranked FURNACE FAU V GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDA ION
I hereby affirm that I am licensed under provisions of Chapter 9REAS SUSPENDED UNIT_ `
(commencing with Section 7000)of Division 3 of the Business and WALL -
Professions Code and my license Is In full force and effect /
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Ukae Number 5196a::& LIC Clava J-o �o o ,
cmaador Data IO.31-93
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❑ I am exempt under sec Plan check fee
B&P C f«tha reason PERMIT ISSUING FEE i i O
Oats r TOTAL FEE W
Signature a.
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT -
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I hereby affirm that I am exempt from the Contractor a License Law NAME
for the following reason (Section 7031 5 Business and Professions w�
Code) ADDRESS �ACCT.A
E] I as owner of the property or my employees with wages J. .� 122.''
as their sole compensation will do the work and the CRY TEL NO
structure Is not Intended or offered for sale (Section 7044 1 I 1T'c'1.L�aC
7
Business and Professions Code) OWNER -
❑ I as owner of the property am exclusively contracting MAIL TOTAL 122.25
with licensed contractors to construct the project (Sec ADDRESS E- IAJ 1N _ - f�rV 122.25
lion 7044 Business end Professions Code) p MG4n 11G i
CONSTRUCTION LENDING AGENCY CITY TEL S a. - .00
I hereby affirm that there Is a construction lending a ency for COFi1HACTOR ,
the performance of the work for which this permit Ps Issued r
(Sec 3097 Civ C)
Lender s Name ADDRESSSd-v 77 I=-0o]1 7/26/93
cm TEL No qCt 1 0914 1 ' AM 8:071
Lender a Address C.�d _ i
I certify that I have read this application and state that the above LLIICENSE NO CLASS L
information is correct i agree to comply with all County ordmances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mantioned
property for inspectwn purposes SEE REVERSE FOR EXPLANATORY LANGUAGE -
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