HomeMy Public PortalAbout5034 SERENO DR_Miscellaneous__ WORKERS COMPENSATION,DECLARATION 200013 - - - - MISCELLANEOUS APPLICATION
20 OOB30PlYt2/BO
I hereby affirm that 1 have a perti icate of consent to self COUNTY OF LOS *NNGELESBUILDING AND SAFETY DIVISION yV1
insure,or a cerflficate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 C) - - - -
Policy N v-/ ompany FOR ADPL ANT TO FILL INBuir,DINI
® BUILDING ADD S ADDRESS
Certified op Is hereby famished , Q LOCALITY _I
Certified copy is flied with the county b Idm Inspection a ZIP l
6FIFCATE'OF,
mt - - NEAREST _-
CROSS ST j
Date _Applicant ' SIZE OF L NO OF BLDGS NOW ON LOT DISTRICT NOO G UP TYPE EBBED BY a
OM WORKERS ' TRACT BLOCK IAT NO -�` - CONST- _ , O
COMPENSATION INSURANCE +P g AY - - V
No ,cllKlq STATE MAJOR SECOND LOCAL I
(THIS SeCI100 need not be completed if the work mvahed ASSES RMAPEQOK PAGfr/� PARCELB�O ME ZONE SPECIALCONDITIONS — - nl
by the permit Is for one hundred dollars ($100) or less I l/ 1/
1 certify that In the performance of the work for which this &LNO
permit is Issued I shall not employ any person In any manner _ _ 6,
so as to become subject to the Workers Compensation Laws AOOR1 144 OCCUPANCY GROUP - H
Date Applicant ICITY nP ?
NOTICE TO APPLICANT If after making this Certificate oLlt OCCUPANT LOAD
of Exemption you should(become subject to the Workers - APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code you most forthwith
comply with such provisions or this permit shall be deemed TRAILER USE[I GEOLOGY INSPECTION El P10 Spec Krlowl Elrevoked ❑
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION❑ Panic Devices
1 hereby affirm that I am licensed under provisions of Chapter SAFETYPERMIT❑ (LISTITEMSBELOW)
9(commencing with Section 7000)of Division 3 of the Business NO OF Exna
and Professions Code and my license is in full fond effect
PARKING REO D 9PROVIDED
License Number 4opm� Lic Class 7-9 " 4 SPACES
Contractor�r�j,�(Q� L(X� S ".�^/(. �( /3 + LIMITED TIME USE
F] I am exempt from the licensing requirements as I am a FROM DATE To DATE
licensed architect'or a registered professional engineer
acting in my professional capacity (Section 7051 Business SIZE OF NO OF IN SPE TOR S
and Professions Code) EXISTING BLOC STORIES TORE
LIC Or Reg, NO — - Date rI PRESENT USE OF BUILDING FINAL APPROVAL
HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS 330 •242.7(]
ON LOT AND USE -
1 hereby affirm that 1 am exempt from the Contractor s License 1 ITEMS
Law for the following reason (Section 70315 Business and - - -
PlOfe5510 Ode) ! NO PARKING , TOTAL 242. 70
LrJa/ owner of the property will do the work and the 'CES PROvioeD �]6�]
structure is not Intended or offered for sale(Section,7044 PROPOSED USE OF LDING `^"�" 242.70
Business and Professions Code) R _ _ _ _ _
.00
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for _ 1 -�7 3796
the performance of the work for which this permit is issued PgoPOBED MAXcc
Len -
L 3097 Civ C) 5651 1 AM 9%40
Lenders Name APPuu Nr rnmrrl TEL NO
Lenders Address ADDRESS ,
I comfy that I have read this application and state that the
above information is correct I agree to comply with all County PERMITFEE OQ
ordinances and State laws relating to building construction and z
hereby authorize representatives of this County to enter upon ISSUANCE FEEQQ
the above-mentioned prope y for inspection purposes is.J�
FEE it• A
SEE REVERSE FOR EXPLANATORY LANGUAGE -
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