HomeMy Public PortalAbout5266 SERENO DR_Mechanical__ .WORKER I have
a ceN lfTION DECLARATION 9I� APPLICATION FOR PERMIT LIME GREEN
1 hereby affirm that I have a cenllicate of consent to Bell Insure
or a certificate of Worker a Compensation Insurance or a certified .' HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sac 3800 Lab C)
Po1icy No ' Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Certified coq la hereby furril ed '
❑ Cartniad copy le filed with the county building awpectlon FOR APPLICANT TO FILL INDING S
departmentM(PRIOR TYPE ONLY)
Date ApplicantLOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU _
(This section need not W completed If thework Involved by the ASSESSOR
ME OO PAGE PARCEL
Parrett 4 for one hundred dollars($100)or lees) AIR HANDLING UNIT CFM
owmcr eo vaoceesm ev
I certify that In the performance of the work for which this permit '
' is Issued I shell not employ any person In any manner so as to BOILER BTU
become subject to the Workers Compensation Laws ,
COMPRESSOR BTU
DAM M6FH:IU19901111WiE
Dale APPllcam VENTILATION SYSTEM
NOTICE FfO APPLICANT If after making this Certificate of ROUGH /2 3
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL '
pronelons or this permit shall be deemed revoked FURNACE FAU O VRY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VX' i-DA-TON
I hereby affirm that I am licensed under provisions of Chapter B HEATER SUSPENDED UNR_
(commencing with Section 7000)of Division 3 of the Business and WALL
,Professions Code and my license isInfull force and effect
LKxrrse Number 5 tOad� Lic Class C--XO ..� _ �•
•Contractor Dale !O-(-(-C( Poo. ACCT.¢ d
'3Us
F11 errl exempt under Sec Plan check fee 122.28Q
1 ITEM
B aP C for this reason - PERMIT ISSUING FEES D O
TOT 1�7 '7
Date TOTAL FEE a _
E
Signature CHECK 12 .t
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT _ CHANE-- trTwVG . '
I hereby affirm that I em exempt from the Contractor a License Lew NAME ► _.
for the following reason (Section 7031 5 Business and Professions (�y�
Code) ' ADDRESS '0000-01'L
001 7/26/91-
I
/26/9:I all owner of the property or my employees with wages , r1'
as their sole compensation will do the work and the CRY TEL NO .. 091? 1 AM vl:cl0
structure is not intended or offered for sale (Section 7066 '
Business and Professions Code) OWNER ,
❑ I as owner of the property em exclusively contracting MA
with licensed contractors to construct the project (Sec ADDRESS '
tion 7046 Business end Profeaelons Code)
CONSTRUCTION LENDING AGENCY CT' TEL NO
I hereby affirm that there is a construction landing agency for ►
the performance o1 the work for which this permit la issued CONTRACTOR t - - -
(Sec 3097 Civ C)
ADDRESSQ
Lender a Name a ' _
CITY
TEL NO
Lender a Address STATELIC SS O�- /J O '
1 csrhty that I have read this appllcatlon and state that the above LICENSE NoIg CU
Information is correct I agree to comply with all County ordinances
And State laws relating to building construction,and hereby authorize ,
representatives of this County to enter upon the above mentioned
property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
o o Agar