HomeMy Public PortalAbout5262 SERENO DR_Mechanical__ WORKER have a certificate
DECLARATION Pa001aDPW 9/aa APPLICATION FOR 'PERMIT LIME GREEN
]0-OD46
1 hereby affirm that I have a cerilflcete of consent to self Insure
or a certdicete of Worker a Compensation Insurance or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3500 Lab C) -
Policy No Uornparry COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
�' ❑ Cartlfuld copy is hereby furnished
❑ FOR APPLICANT TO FILL INdaparteulLario �7 Q
�m Is flied with the county DuIIMrIp maperdbn (PRINT OR TYPE ONLY) Y OL
_
Dale Appllcam LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
+ CERTIFICATE OF EXEMPTIONFROM WORKERS - VP I
NEAREST
CA099 ST
Eo AM 11"
COMPENSATION be completed
INSURANCE ABSORPTION UNIT Hill ASSESSOR r
(Thio tl Is for wed not be completed 0 the wort Invoked by the MAP BOOT( PAGE PARCEL
' permit la for one hundred dollen(!100)or lap) AIR HANDLING UNIT_CFM emm
I certify that m the t employ
an o1 the work for which this permit �O� L
is Issued I shall not employ any person In any manner w as to BOILER BTU
become wbfect to the Workers Compensation Laws ' ,
COMPRESSOR BTU O
Date Applicant VENTILATION avST7DA
MPROVAIa eon wsR�ale epaATura:
NOTICE 70 PLICANT It altar making this Certllicete of ROUGH
m
5__L4r_ 7J,
Exemption you Should 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 revoked FURNACE FAU O VfTY
4 � i_
LICENSED CONTRACTORS DECLARATION FLOOR BTU V LIDAT ON
I hereby affirm that I am licensed under provisions of Chapter B NEATER SUSPENDED UNR_
(commencing with Section 7000) of Division 3 of the Business and WALL
Profess e"Code and my license Is in full force and effect
L I �/� T N
Lkanee Number �� ? `a= Lk Clem C_'4 10to O L'LJe
Came,-rax=`�.�n•t_T_n... . _ �Y_ Ee 10-3i—�3 � ,
Elm I aexempt under Sec .. Plan Check fee - $8
B eP C for ewe reason PERMIT ISSUING FEE$ *Jq O
Date TOTAL FEE W
CL
Slgnetun C0ACCT.a
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT _ ,i . Z
I hereby eHirm that I amexempt from the Contractors Licence Lew NAME .
for the following reason (Section 7031 5 Business and Professions T103 M.25
Code)
❑ � wages 1 ITAADDRESS - _ ITEM
I as owner of the property or my employees with Gt t31
as their sole compeneatlon will do the work and the crTy TEL NO TOTAL 122.25
structure Is not intended or offered for sale(Section 70M
Business and Proleeaons Code) OWNER �.
❑ I as owner of the property em exclusively contracting
with licensed contractors to construct the NAIL
project (Bac ADDRESS WAIAie i.HANGE •W
A lion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CfTV TEL NO —
I hereby affirm that there is a construction lending a ency for 7
the performance of the work for which this permit Pe Issued CONTRACTOR d- ,�, , 000O-C1�1_ 7�26� .•
(Sec 3087 Civ C) irk i a
0913 1 -Ali 8:06
Lander a Nemo ADDRESS
CITY r� TEL NO
Lender a Atldmss _
I certify that I have reed this application and elate that the above KAET�ISE NO Cu39 '
Information Is correct I agree to comply with all County ordmerlces
and State levet relating to bulking construction and hereby authorize '
representatives of this County to enter upon the above-menttoned
pro er for I speotlon purposes BEE REVERSE FOR EXPLANATORY LANGUAGE
7 t3 3 - -
OF MRI TOR• rr DATE I