HomeMy Public PortalAbout4923 SERENO DR_Building__ APPLICATION FOR BUILDING PERMIT
r COUNTY OF-LOS ANGELES EIUIL.DI G AND SAFETY
WORKER S COMPENSATION DECLARATION PUCANT TO FILL IN BUILwNG
I hereby affirm that I have a certificate of consent to sell Insure q 235E¢l?IJO
or a certificate of Workers Compensation Insurance or a certified
copy thereof(Sao 3800 Lab (C) rTEMyJOLE GLTy, �91ne> '
Foley No Company LOCALIT
Pal
SIZE OF LOT NO OF SLOGS NOW ON LOT
❑ Certded Copy Is hereby rum Ahad I'Lr�fmO I NEAREST CROSS ST
❑ Candied copy a filed with the county budding Inspection TMCCT . BLOCK LOT NO
department 5' USE ZONE MAP NO '
Dats Applicant /T AT
assE 15,8 f PAGE
1 PARCEL
/�-a VECAL CONDITIONS GvmP D
CERTIFK' WORKERS' TEL NO
TOM 1ANM£ IZ$'7 L
Wlm-.N 1000 VES NO
COMPENSATION INSURANCE F !
AGGRESS d3fRICT GROUP TYPE CONST FlRE PROCESSED BY
(Thisdolga ssection($10 need not be completed d the Permit a f«one humored q gtay �jQ�fJO FiT.
dollars (a too)or less) _
I certify that In the performance of the work f« which this permit '('FAMPLE 1:4TY
9IZBD _ AC(
s Issued I shell not employ any parson in any manner So as to
ARCHITECT OR ENGINEER TEL NO 1
become subject to the Workers Compensation Laws STATISTICAL C FICATION -
cA7sTbM p�tloNS 55-7• N791"1 AP`1. I1 U NDO
Date Appoanl AGGRESS CUSS NO DWELL WITS
NOTICE TO APPLKAAfT It after making this Certificate of 111 9. VeWA014T AVE A RECUIRED TOTAL ExrTr
r..`/
Exemption you Should become Subject to tfe Vbrkers CONTRACTOR TEL NO SETBACK YARD HWV PRCIPlAtipw NOT N'-r .y'!
Campensaton provLwons of the Labor Code you must forthwith (\ 5villj a AS OwaE.R
compy with such prweone or the permit shell be deemed revoked ADDRESS LIC No PL NT —(HANK •017,
LICENSED CONTRACTORS DECLARATION ' SIDE
CRY 11C CLASS P L
I hereby affirm that I am licensed underprovmore of Chapter 9 SEWER MAP I I I—II 1J•L i!19:
(commencing with Section 7000)d Drvsion 3 of the Business and 9O NO OF STORIES NO OF FAMILIES / -
Professions Gods and my Ilcense is in full force and effect 2 NEW ❑ BK I'O , J J� 1 An j:5
lJCarLse Wartier Lc Clew SCRIPTIDN F ADD VALUATION p�
V:Vm ODs LBGG o ContractorDate $
ALTER ❑ OOD W
A�nlr�otil 36oQ�
❑ 1 am exempt under Sec _ REPAIR ❑ $ Z
BBPC for this reason !) DEMOL ❑ LO MA P/C•
USE OF EXIS
Date '{� URM ❑ 1 ==
Signature V` APPLICANT(MAJiI TEL NO LDMA Pmm♦ x11.1 T.i
VOn/N�cTT�A✓ Z o 4 7 z
�I m owner of the property or the
a work
and
he wages ns 1 p ,�_�., 1)27.5)
flea sale dor offered
will do the work and the structure d A ES a HC
not Intended or offered f« sale (Sedan 7044 Business erltl ® Ill �• 61QM1mN? /+✓` FelA1 1 ITEM'
ProlessKlM Code) wu TIE.rPuuJrt pit FUTUIE awwq occurwr IwiIXE A IpURpws MUEwu O
❑ I as owner of the property am Exclusively contracbrg withore A NAxTLrE coNwuwa n HA1AA0(%A4 MATEPYL EauuL To CR GREATER rwv!rIE I
nsYES 13 1. I_HEI_k
licensed contractors to construct the project (Section 7044 s s oN TUE HA2ARO011S MATERNL9+EawAn«+aiAOE+ >
Sus inew aProfessors Code) YES 13 NO
and 1J7G._C
wLL TIE •lTEIDED USE « TIE 9Oi4 BY TE ARLK.rM 1044 IVTURE 6Ul kn"
OLCURWL rEOIIIVE A hAGE T FOR W1RICT( 10N OR EE0 ERADN FROM TIE SOUTH ' I , ,!( ' •C Hr1N1iE •rlrl
CONSTRUCTION LENDING AGENCY cU�OEu�ESOIuu1v MANAaEMENr DISTRICT IecAa.im sae PERAYTTNO c1ECKusr
I hereby affirm that there s a construction lending agency for YEs❑ Iq / , T ','}
m the performance of the work for which the permit s issued(Sec IHAVEiEAD TIEHAZAnCX1U9 WTEFYLSKOPoMTgNG1YlE AIO TIESUO,OPEIOATTYIO I1! i V I��•JfJ-1�1_f�l l/ � 174
3097 CN C) GIECi41ST I UNCER4UND NY REOLMEI,EHT9 UNDER THE Los ANGELES COUNTY COLE t '
ME 2 CHAPTER 220 SEGT S 2]0100 THRg1aH 210 140 CONCERNND HAZAAWLLS � 64)9 1 Ar( _.i 11 I
Lendeir a Name AwTEPo REP«TrmG AND FOR 0e➢1MP1G A PERU!FnCLI TE SCALAO
Lenders Address
� PIKI1 w.m•1
Q I Certify that I have read the application antl State under penalty PC FEE PERM FEE
�C �] O '7
}' of perjury that the ehpNe information carlect I Bgiee to CorTply �� J �•N� LC /
$ with all county ordinances and State laws relabng to budding
CO and umonze repn9aef11811V8e d the Cpo�ungtay IRSUANCE FFE �J/ h
er Upon Dred property f«Irepactonp�puur B QW
(, i1 V
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INVESTIGATION FEE TOTAL F O , 1- ran
SEE REVERSE FOR EXPLANATORY LANGUAGE