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Home My Public Portal About4909-4911-4913 SERENO DR_Miscellaneous__ WORKERS'C011PENSATION DECLARATION CE 875 h 1 841 M ISCELLANEOUS APPLICATION CE 876 I hereby affirm cert that I have a Certificate of consent to ser COUNTY OF LOS ANGELES • BUILDING AND SAFETY DIVISION insure, or a certdlcate of Workers Compensation Insurance,or a certified•copy thereof(Sec 3800,Lab C) Policy No Company FOR APPLICANT TO FILL IN eulLDlna O ADOR¢SS Certified copy is hereby furnished BUILDING wooweSS V /[l ocwurr Cued copy is filed with the county building uupectwnLOCALITY NEARESTIF department CROSS ST Date Applicant NEAR QST DISTRICT NO a cup Tr P¢ E.SED OY i CROSS ST / D G �7 CONE CERTIFICATE OF EXEMPTION FROM WORKER$' LEGAL < .l 5r &06W114 COMPENSATION INSURANCE DESCRIPTION LOT No FLOCKM^ ISN'•^ STATE NArow a¢corvo LOCAL NO• tC CLCI NO OF ELOOE (Chis section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less) uas oC F SIZE or LOT xiSYiNG LOG /�z 1 Certify that in the performance of the work for which this ¢ permit is issued, 1 shalt an not employ any person in any manner Orn 9 v t so as to become subject to the Workers' Compensation Laws NAIL OCCUPANCY GROUP Date Applicgnt ADDRESS f cro W NOTICE TO APPLICANT If, after making this Certificate of mrr IT+oL -�7 OCCUPANT LOAD H Exemption, you should become subject to the Workers' i Compensation provisions of the Labor Code, you must forth- APP LICA ION FOR EXIT HARDWARE with comply with such provisions or this permit shall he TRAILER LIS¢ ❑ GEOLOGY INSPECTION ❑ NO Spec Knowl deemed revoked LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices I hereby affitm that I am hcensed under provisions of Chapter 9 (commencing with Section 7000) of Denson 3 of the Busy 49AWKYY PERMIT ❑ (LIST ITEMS ¢ IN no or EXITS ness and Professions Code, and my license is in full force and �/ •PROSE R¢OO effect PARKING R E ING D PROVIDED [� License Number Lie Class LIMITED TIME USE i Contractor - Date SAT. aArt I am exempt from the licensing requirements m I am a94M r..., TO hcensed architect Or a registered professional engineer SIZE OF NO or rnSPE Crow S acting in my professional capacity (Section 7051, Bus- EXISTING SLOG _ STORIES S wruw¢ mess and Professions Code) FINAL APPROVAL Q ` PRESENT US E OF BUILDING I ( Lie or Reg No Date HONE OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS ON LOT AND USE - — - MI_i1'•.+E " I hereby affirm that I am exempt from the Contractor s I License Law for the followmg reason (Section 7031 5, Bust- rA Hess an j Professions Code) No PARXINa - - s SPACES PROVIDED 1 ITEM _ ,Ras owner of the property, will do the work and the structure u not intended or offered for sale (Section - "- - 234 . 45 7044,Business and Professions Code) TOTAL- t✓M 1 CONSTRUCTION LENDING AGENCY PROPOSED u or Es{ILm �4.45 rva l�l.K I hereby affirm that there is a construction lending agency for the performance of the work for which this permit u - issued(Sec 3097,Civ C) Lender sName 13000-0001 2/19/9= Lender's Address PROPOSED MAX oce Ar110:2D I certify that 1 have read this application FEE application and state that the I above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, - and hereby authorize re resentatives of this County to enter TOTAL P4kH up h above-menti llla property for inspection purposes wd, _/7 �3 SEE REVERSE FOR EXPLANATORY LANGUAGE nature o Perini a Date - i