HomeMy Public PortalAbout5036 1/2 SERENO DR_Miscellaneous__ WORKERS COMPENSATION DECLARATION MISCELLANEOUS APPLICATION
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• CE CE 875 (l l e41
1 hereby a that 1 have a certificate of consent to self COUNTY OF LOS ANGELES \ BUILDING AND SAFETY DIVISION
insure, or n Cort certd`Ip[e of Workers Compensation Insurance,or _
a certifi l copy thereof(Sec 3800,Lab C) a _
Policy No Company FOR APPLICANT TO_FILL IN �` weow¢an Q
Certified copy is hereby furnished BUILDING i
ADDRESS O LOCALITY f
❑ CertTi d Copy is filed with the county building inspection A....LOCALI.. -"10
� / NEARS
department C- CR— ar
Date Applicant NSA RQ ar o RICT N wouP r Pw ce S ar
cwoaf Sr S C CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL ``CC J
COMPENSATION INSURANCE Dea CEvnoN Lor No '37 Q' _� BLocK =P11µ ]`s�cawcLil STATE MAJOR SECOND LOCAL
0 of
No Or BLDGE
(This section need not be completed if the work involved TRACTF NOW ON LOT USE ZONA: SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less) use: or - I^
SIZE OR LOT EXISTING BLDG p(�
I certify that in the performance of the work for which this A,
permit u issued, I shall not emplo y person many manner O..xeR d /LN
so as to become su ect to the Tse Come sation Laa ssation Laas 1 CD
�/' �� MAIL - OCCUPANCY GROUP_ o
/1 Da[e hwnt ADDRESS SQ y � - , I k . \
PP y da y
NOTICE TO APPLICANT If, after making this Certificate of CIr Y woL�`� Q OCCUPANT LOAD
Exemption, you should become subject the Workers APPLICATION FOR EXIT HARDWARE
Compensation provisions of the Labor Code,, you must forth-
with comply with such provisions or this permit shall be TEAILSR USB ❑ GEOLOGY INSPECTION ❑ NO Spec Knowl
deemed revoked
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
1 hereby affmn that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Dwmon 3 of the Bust NO
reRMlr ❑ (UST ITEMS BELOW) No OF EXIT$
ness and Professions Code, and my license is in full force and
effect PARKING
fPw CEa REO D PwOVIDeO
License Number Lic Class LIMITED TIME USE
Contractor Date D.T. AT.
1 am exempt from the licensing requirementsJ
licensed architect or a registered professional
fesvonal az lama a engineer SIZE or No Or INSPECTOR f
acting in my professional capacity (Section 7051, Bus- SXlanxa BLDG ISTORtU5
f xwTURQ
mess and Professions Code) - FINAL APPROVAL
Lic or Reg No Dale PRESENT USE or BUILDING
HOME OWNER-BUILDER DECLARATION No Or EXISTING BUILDINGS •w
GN LOT AND USE ANT.T
I hereby atTum that I am exempt from the Contractor s
License Law for the following reason (Section 7031 5, Bust- 3307p� �r1
ness and Professions Code) NO PARKINGW...S.1
1, as owner of the property, will do the work and the SPACES PROVIDED c \\f 1 ITEt15\ \ {s
structure is not intended or offered for sale (Section �`
7044,Business and Professions Code) •v �` '
TOTAL" $�-:�t+��1 ��r1
CONSTRUCTION LENDING AGENCY PROPOSED USE oP BUILDING �` �'•\= ) _ CEp(' _ s •80.50
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is t \ `% -00
untied(Sec 3097,Cry C)
Lender's Name My�Ic
PROPOSED MAX Occ `�nyOOD 0001 7//6/89
Lender's Address O _PERMIT RCE 4341 1 AN 8:29
I certify that 1 have read this application and state that the
above mforrnat ss correct I agree to Comply with all County ISSUANCE FEE ) -
ordinances to laws relating to building construction, '
and hereb u me representatives of this County to enter TOTAL PHH
upon the o ntioned property for inspection purposes
(
//J .� F9 SEE REVERSE FOR EXPLANATORY LANGUAGE
re uof Permittee Date n I 0 }
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