HomeMy Public PortalAbout5018 SERENO DR_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKERS COMPENSATION DECLARATION FOR APPLICANT TO FILL IN '
I hereby affirm that I have a certificate of consent to self unsure ESS Lrl
or a certificate of Workers Compensation Insurance or a certified
(/ Pie
✓
c7fcopy thereof(Sec 3800 Lab C) ZIP P(PI '� t LOCALITY
W1 9¢E OF LOT tq OF BLDOS NOW ON LOT
❑ Certified copy is hereby furnished NEAREsr CROSS
❑ CertihadTRACT BLOCK LOT NO
copy b filed with the county 1w1ld1np mrospection
T department - USE ZONE MAP NO
Date Applicant ASSESSOR MPP (j PAGE RRL r _�
J O D 012— U l srEpAL CONDITIONS/x/V
CERTIFICATE OF EXEMPTION FROM WORKERS' ° 'Eq 5 tEL No `
COMPENSATION INSURANCE WT-11N 1000 FT OF SCHOOL?
YES No
(TMs section need not be completed If the permit is for one hundred ALLgEPP '
dollars(S 100)or lees 1 pSTRICT GROUP TYPE CONST FIRE 201E PROCESSED BY `
I cert) that in the lam' �
certify t employ an d the work for which this permit .two Y y
b become
I shell old empty arty person in any manner so a9 to AR CT OR ENGI EER TEL NO �I O Y �7('
becCrrme subject to the Workers Compensation Laws STATISTICAL CLA/�Sy�FrICATION APT CONDO
Data Applicant CLASS NO '�V ONELL MITZI� 1 I EM'_
NOTICE TO APPLICANT If after makig fhb Certificate of d REWIRED TOTAL SE E)d^u ,rj'!
Exemption you should become subject to the Nbrkers CONTRACjpg , TEL NO SET BACK YARD HV/V PROP WOfN_
CpnpentsetDn provbtons of the Labor Code you must forthwith a� FRSET
ONT
comply with such proYsrone or thus permit shall be deemed revoked ADDRESS LIC NO P L
LICENSED CONTRACTORS DECLARATION PILE
GTV LIC CV56 P L
I hereby affirm that I am licensed underpmvlsions of Chapter 8EWEq MAP
(commencing with Section 7000)of Dwbion 3 a the Business and FT NO OF IES NO OF ES D
Prolessare Code and my license is n full force and effect Q NEW BK � PO ► 731
O
License Number _ LC Class. OF K ADD _ ❑ WLUATION
Contractor Date ALTER ❑ $ ��� Ir
❑ 1 am exempt under Sec REPAIR ❑ $
B&PC for this reason DEMOL ❑
t LOAD P/C• W
' Date USE of nNG BIm URM ❑� - - d
1 z
Signature
owner a the property or my employees with wages as iEL 3 LpM Pim• t 0 " ACCT.* Z
❑ 1 as
their sole compensation will do the work and the structure b E �rL�
not intended or offered for sale (Section 7044 Business and FINAL D Q `M 1805.00
Professions Coda) wxL TIE,wPLIcwT oR FUTURE eu¢nNa BccLFrxr NuntE A Iuz.Ioous MATEILAL D 1 ITEMS
I as owner d the property am excLsrvely contract) with oR A AaxTAE CONwrrm A IlAzuaoous AureawL EOU&m OR BREATER TIYN TE - p/'L
mg NApffR9RECaEOON HAI.AAOWaAIAtEWA1.4NFOfWATK1NOl0 .>• FINAL BY > `•TUTAL 1805.88
mCertsed contractors to construct the project (Secban 7044 RS❑ �m:m /' - t �-"' •, ' r
Buanesn and Professions Cade) �y 1 .
win THE PRENDEO USE M THE BIIDLNio aV TIE pPRioNIT OR F R BInISNO
OCCIiMNT REIXAPE Fe CORCT(CT10N OR ME cmF1C.(nmON Flipp THE T
CONSTRUCTION LENDING AGENCY CWSr AIR Ouunr Nr pentlLT 1ecAaAmt SEE FERARrTwp clECKusr FOR I ( .00
auDEUEs 1 1
I hereby affirm that there Is a construction lending agency for t YES❑ No
ly the pBrtpmarlCeathe work for which tW permit bbelned(SBC IHAIE FEAD TImE HA2NT000S MATERML9lFCR'MTICNPUDE ANp TIE 9CAgW PER.fTTH10 ry _ ` ' V 1 4/11/96
m 3097 DnY C) ' c CKUm I UNDERSTAND Art'REWREMENTS UNDER TIE LOS 010ELES COUNry CODE , t
TM.E R 220 SECTIONS 220100 TMOUa11220140 CONCEWiNG RALP s
Lenders N1arne 11AiE HENRt• O�e�NNo A PERVI r FROII TIE SCApMD 1 [:p2 A 1 AM 8:30
Lenders Address r JOTLJ
o � I
I certify that I have read this app)"" and state under penalty C FEE PERMIT FEE 3
yz� d perjury that the above Information b correct I agree to camp ,{' Q f�
Fi with all county odmnarDes and State Dans retating to bulldlr� O ..A ✓
corestruGron
�h— . represeneatrres of t1W reoses I.SSl1Ar10EFEEa -7Wto soar fartims of t e Cos��sr ./1[J
lNESTIGATK)N FEE TOTAL FEE Q�•
esu..a
SEE REVERSE FOR EXPLANATORY LANGUAGE