HomeMy Public PortalAbout4947 SERENO DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION 78M444
CE'875 (280) MISCELLANEOUS APPLICATION {�
I hereby affgtp that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION (J
• msure, or a cer.Bmate Ot Workers Compensation Insurance or
a ceAiV copy thereof(Sec 3800,Lab C )
Ajii Policy No J
Company FOR APPLICANT TO FILL IN BUILDINo 4
�/' wDDReas
❑ Certified copy is hereby furnished woo eaS y- LOCALITY
❑ Certified copy IS filed with the county building inspection NEAREST - r-
deDsr[ment Lo cwuTv CROSS is
Date Applicant NEAREST DISTRICT NO GROUP TYPE PRO aa60.E
^ CROSS ET eC CONST_ /
CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL - V
COMPENSATION INSURANCE 110
DSac Rivn ON Lor No BLOCK IaNwA STATE MAJOR SECOND LOCAL
No OP ei.oas NOP (C,RCL.1 d
(This section need not be completed if the work involved TRACT NOW ON LOT uae :ONE SPEuwL co rvinnoNa 0
by the permit is for one hundred dollars (S100) or leu)
uae of
Srxe OF Lor Extanno SLOG
I certify that in the performance of the work for which this
permit is issued, 1 shall not employ any person In any manner OWNER J.+ F-
so as to become subject to the Workers Compensation Lugs MAIL OCCUPANCY GROUP p3 UU
/ wo DR ESS -7 /`� to
Date Applicant
NOTICE TO APPLICANT If after making this CerNBcate of� crcr NOL —7 �j� OCCUPANT LOAD 2
Exemption, you should become subject to, the Workers AP (CATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you must forth
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION O No Spec Knowl ❑
deemed revoked
LICENSED CONTRACTORS DECLARATION occuPwrvcr inSPecnoNix Panic Devices ❑
I hereby affirm that 1 am IiLensed under provisions of Chapter SAParr PERMIT q (LIST ITEMS BELOW) NO OF EXITS
9 (commencing with Section 7000) of Division 3 of th" B us'Bus'
nese and Professions Code and my license is in full force and PARKING
effect f SPACES REO OF PE oviD Eo
License Number Lie Class I
LIMITED TIME USE
Contractor Date aATR RATC
T.
❑ I am exempt from the licensing requirements as I am a Pno
licensed architect or a registered professional en weer alae of NT oP / M �{ C �INSP eroe S
acting in my professional capacity (Section 70518 Bus- EXISTING BLDG srORIEa -"�'� J "CY✓YilPr wruwe
mesa and Professions Code) PRESENT U5E OF BUILDING FINAL APPROVAL �/���
Lie or Reg No Date C
NO oP EXISTING BUILDINGS :939 & 7A
HOME OWNER BUILDER DECLARATION ON LOT AND USE # A A a A 3()
1 hereby affirm that 1 am exempt from the Contractors 2 • - 8050
License Law for the following reason (Section 7031 5 Bus'
ness and Professions Code) NO PARKING
SPACES PROVIDED . . 8 0 5 0 5
Ell, as owner of the property will do the work and the ,
structure is not intended or offered for sale (Section O 7 26-83
7044, Business and Professions Code) PROPOSED USE OF BUILDING
CONSTRUCTION LENDING AGENCY, ^
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit Is '
issued (Sec 3097 Civ C)
Lenders Name
PROPOSED MAX occ
Lender's Address PERMIT FEE 0
1 certify that I have read this application and state that the
above information Is correct I agree to comply with all County ISSUANCE FEE 0 Q
ordinances and State laws relating to budding construction TOTAL FEE
and hereby authorize representatives of this County to enter
U po the ebo men oned properly for ms ection purposes SEE RR ERSE COR EXPLANATORY LANGUAGE
..i 7/ �v��u•r �d J93
Signature of Permittee Det