HomeMy Public PortalAbout5016 SERENO DR_Building__ _ *APPLICATION FORAL'JI-LDING PERMIT
COUNTY OF.LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION I FOR APPLICANT TO FILL IN
I hereby affirm that 1 have a certificate of consent to self msure NG Ayt ((�•
ora certificate of Workers Compereabon Insurance or a certified
copy theiaof(Sec 3800 Lab C) 1 P
Policy No Company 'SIM OF L
NO OF SLOSS.NOW ON LOT
El
copy s hereby furnished NEAREST CROSS
ElCee �rtleZONE copys filed with the county building inspection TRACT BLOCK 1 LOT NO , USE NE MAP NO
Date Applicant
ASSESSOR MAP ` PAGE I� PARCEL/ �J
/�
I SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS I iTEL r-676tel- YES INSURANCE WITHIN 1"0 FT OF SCHOOL'
NO
(This sector need not be completed If the permit is for one hundred ADORE `r 714 L aSiitCT GROUP TYPE CONST FSE IDNE PROCESSED B1'
dollars IS 100) or less) !
I cerbfY that in the performance of the work for which this permit Crry \} LP
is Issued I shall notL
empty any Person at any manner so as to
become subject to the Workers Compereaton Laws ECT R i t TEL NOprr�
n� I ', STATISTICAL IFlCATION APT1 I Lli=--
Date Applicant CLASS NO DWELL UNITS
NOTICE TO APPLICANT If after making the Certificate of Mrnz(QAeAz REQUIRED TOTALS FROM EXIST
Exemption you should become subject t0 the Workera JADDR�ESS
R TEL NO Rx
SET BACK YARD FRNY PROP Y! r 1..L
Compensation provisions Of the Labor Code YOU must forthwith
comply with Such provsons or the permit shall be deemed revoked _ LIC NO pFR Ni CHANGE
LICENSED CONTRACTORS DECLARATION ' - UC CLASS _ SIDE
hereby affirm that I am licensed underprovecrs of Chapter 8 \ SEWER MAp _LL_—_ L.
(commencing with Section 7000)of Division 3 of the Buseesa and SRE NO OF EMS NO FAMILIES
PrOdoeSIOnS Code and my license s In full force and effect d NEW BKc,,IPG 0 ,
Lucaroe Number Llc Class P OF RK ADD ❑` muxn Q
Contractor Date ¢:ALTER ❑ $ (
❑ Ilam exempt under Sec REPAIR El $
BdPC for the reason DEMOL ❑ Lob1n PTC W
Date USE OF EXISTING BLDG URM ❑ 1 D_
SignatureAPPLI ( TEL NO LDRA4 Firm♦ A
ElI as owner Of the property or my employees with Wages as = ACCT.T
their sole compersaton will do the work and the stncO
tum s 3J'� 18 .88
not intended or offered for sale (Becton 7044 f3sntea9 and O FINAL DATE Q
Professions Code) 1 ITEMS
VR THE APFVO De FUA WMINp O(:GIMHr HANDLE A R�ZMDOIe 4 THE ...
I ae owner of the Property am the p rvey contract wM OR A N-rs R co ONO TO A HAZARcus MnvLs EQuAwon ro OR ORPwreR rHAi ire
� AMOU1rt9 SPE DOH DW9 NATEeILLa INFOMUTeN pLOE'I FINAL � I> '` TOTAL 1805.88 W
Businkccnses andconProfessions
to construct the protect (Becton 7044 r 6❑ �- j
Business and Rolessore Code) �o (`.
"LL RQ P �ED USE 6111E eUIDVXi BY THE AFPLK/,Ni Dn RCNI BUl unH •OV
OCCUFl,M 1>td A PErO.fr FOR ISTACT UDiIdi DR ME%RMn-n G CH XU FOR --1 ,f\
1 !
CONSTRUCTION LENDING AGENCY eOASr w+ rAHA6r.�Hr olsrRcr lscrnrol ME FeRunTea peeKusr FOR >+ f
onAOELres ! n
I hereby affirm that there Is a construction lending agency for ` _ `.
,v the performance of the work for which the permit Is issued(Sec vsa❑ Ho !
m 3087 Civ C) iM
AZAHODIe MATERALBNFORMATK)N OUIOE ANO THE SLApAp PPAAR➢Vp ) j \ i i! • 1C
6LmAlDMY PEIXAREMENi3l 8ULOS ANGELES DV W V—l!V V1 4/11/%Lendera Name ZZO 9EDn1CY19 ar,tOO AIKRIarYtOI000N;EaID s n R Daws uiD A PPoAi EADM rrf sc�gNo y c 1 8;
o Lenders Address !
0 oAUH oA Hour I
I certdY that I have above
the applicationutand state res t comply PC FEE / PERMIT FEE .c-
of perNry that the above mformahon s correct I agree ro comply � (O G/ �.J
n with all county ordinances and State laws mating to budding
cost Otlonl and ereby hon a rapresentatnes of the County ISSUANCE FEE 1
to ant a ve h etl property for Inspec pwompses
a
/ INVESr1GATI0N FEE TOTAL FEE 0� v
SEE REVERSE FOR EXPLANATORY LANGUAGE U