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HomeMy Public PortalAbout5039 SERENO DR_Building__ WORKERS' COMPENSATION DECLARATION [,hereby affirm that I have a certificate of consent to self APPLICATION FOR. BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec 3800, Lab C) COUNTY OF LOS ANGELES '- BUILDING AND SAFETY Policy No -•��1�T'ompanye � _ BUILDING ❑ Certified copy Is Hereby furnished FOR APPLICANT TO FILL IN ADDRESS d 3y 4-o ICA& © Certified copy is filed with the county building Irepec- BUILDING - ADD RE55 hon department _ LocALm- Dates If CERTIFICATE OF t s NO OF ON NEAREST FROM WORKERS' SIZE OF LOT X NOW LOT 'T CROSS ST COMPENSATION INSURANCEASSESOOKSOR O (This section need not be completed d the permit Is fa one TRACT b BLOCK LOT NO MAP BO PAGE 014 � PARCEL � hundred dollars ($I00)or less ), NO 8- USE ZONE MAP All aG J' I certify that in the performance of the work for which thisLsa. _ SPECIAL i a permit is issued, I shall not employ any person In any manner ADDRE O CONDITIONS O so as to become subject to the Workers ws Compensation LoU CITY zip I- ODC Date Applicant ARCH TEL DISTRICT GROUP TYPE PROCESSED BY O NOTICE TO APPLICANT If after making this Certificate of - ENGINEER - - NO C Exemption you should become subject to the Workers ��� •3 .' Compensation provisions of the Labor Code, you must forth- - ADDRESS - _ APT CONDO with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION Z deemed revoked CONTRACTOR llCO CLASS NO DWELL UNITS__ LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 LIC I SEWER MAP (commencing with Section 7000)of Division 3 of the Business CITY CLASS BK PG VALIDATION and Professions Core,and my license n in full force and effect NO CHECK _ - - " FT NO OF I License Number hO'L-1:3"1l LIC Class��� �E a ORES 1 [FAMILIES 044E�-I, VALUATION ' lA w�.p .•{Oe/'S.Dalesv.s�i= _ DESCRIPTION OF WORK NEW tUL $ �� Contractor - - ADDIs LI ► ❑1 am exempt under Sec _ ALTER_❑ B 8P C for this reason REPAIR ❑ $ t ' .L .. USE OF _ Dote OF BLDG 'DL APPLICANT L .. TEL I SlgBUILDER DECLARATION r (PRINT) - NO 4 - DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS - FINAL Low for the following reason (Section 7031 5, Business and B Profess om Code) - ENT - Y _ BUILDING I ❑ I, as owner of the property ar my employees with ADDRESS wages as their sale compensation,will do the work and i 44LOCALITY poll - the structure is not Intended or offered for sole(Section TEL _ _ 70 , Business and Professions Code ) MOVING CONTRACTOR NO _ ❑ I as owner of the property, am exclusively contractingWith licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code ) - - VARO FIWY AL LO(FRAM EXIST CONSTRUCTION [ENDING AGENCY ��UBACKIIED - . ... ., I hereby affirm that there Is a construction lending agency for FRONT I the performance of the work for which this permit le issued P L (Sec 3097 Civ C ) SIDE PI Lenders Name _ (/ TDMA Rel a t, - P C Fee t Permit Fee Lenders Address , I certify that I hove read this application and state that the Issi Fee �' [DMA PTC 4 above information Is correct I agree to comply with all County Inv 92 10n Fee ordinances and State laws relating to budding construction, Total Fee rLDMA Per. If , Z and hereby authorize representatives of this County to enter - w - _ _r upon the above mentioned property for spection purposes � Z3 Lt RlVOIS!FOR E%PIANATORY IAMGt1AGI tura of AppjKUM or Agent Data APP=A71 IOWFORLBUItDING PERMIT COUNTY OF LOS ANGELES h BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING ADDRESS. ' WORKERS COMPENSATION DECLARATION , I hereby affirm dot I have a certificate of oonWK to sell mule, BLIUM O ADDRESS or a certificate d V*Xkem CanpwtsWw Ins asnce,or a wtiled S 6 JO 3L7 '55MUO WE copy thered(Sec Lab ) 17 0 Policy NO� �-ComPemy swe Fand_ SIZE OF LOT 9 NO OF NOW ON LOT v ❑ Certified copy Is hereby banished NEAREST CFIOSS ST 5(Cartlfied Copy is filed AAUP the County bulding Inspection TRACE BLOC( LOT NO USE ZONE MAP NO �d1 L % _ _ Pte, °" L y ?aSPECIAL CERTIFICATE OF EXEMPTION FROM WORMERS' X 7a i. No COMPENSATION INSURANCE OF x (TMs sectlon need not be completed H the permit Is for one hundred tS 6Al U 11 7� dollen(ff00)or kers) _ I cenify that In the performance of the Work for Which this pemdt r� aP / ? V �Ji '3 IFT is Ise,ted I shall not employ arty pereon In any manner so ae to ARCH OR EtgINEQi become subject to the VA7rken Compmmebm laws J $fi$ �►bi STATISTICAL CLASSIFICATION APT- CONDO Date Applicant ADDRESS _ CLAN NO X010 DWELLUI S� NOTICE TO APPLICANT If after making this Certificated P , ARS Iq REOl1IRED TOTAL SETBACK FTiOkI EXISTEKernptlon, you should become subject to the Workers' CONTRACTOR e' / n f-n�„]� SETBACK YARD Mw PROF LINE WIDTH Compensation pmwslpn of the Labor Code you must forthwith 7_U Y comply with Such Provisions or this permit shall be deemed revoked p r >' ii 3 - Pl.FRONT - LICENSED CONTRACTORS DECLARATION �' CTt' Tei e G i t 47 � ` LJ 8 I herby affirm that I am licensed under Provisions of Chapter 8 �( F7 SIZE No of OF FANILLEs E'ER MAP A7 I .. � (opnenerhdrg with section 7000)d Dlvlebn 3 d the Swire®and .r`2`ir`'`L NEW BK PG 7;;[i'. 76*..�I Prolsaeiorm Code, d I Is In full force and effect , Licence Number Lie Claes WORK ADDw 011 _ 05Contractor N AI F^ ALTER ❑ : 1 ITEM WTAL�i 764 . 37E REPAIR ❑ w�.t�e :Z ❑ I ern exempt under See ',Z IN, s_ BBPC for this reason DEMOL ❑ Pros Gale 113EOFEXISTING BLDG LOWURM E, 30 Opo 0o CHANGE _I sgnahae LOMA Firm a ❑ Lae owner of the Pn>osM or my employees with wages as � ' IIQ@�001)1 d4 �,;1I? their sole compensation,will do the work and the structure Is I AOORF� O • I A 1 t0." ye Tp1k cT , •• O'h T-_�. not Intended or deed for sale (Section 7014. Business and FINIAL DATE I�-� t < 943 _ . AM11:�1� wu. WvrU LIC JJRORFurUREeIxILMIaoCC1AAMThU1ELl AhM7AAOp1 TlM THAN I Professional ow re Code oR A rnxluRe OpIMeeNo A hW/JOOIIe IMTEr1UL xclrAL TO oe oaEAroh ThMN �� 171C.17 l a owner 1b the property,C0( t m ethe "ly C(SLctionG with � TI�ANOLMa�moN Thi huwmps rAthaeua eaOIYRKIN Wlme) ►outer ,: :NECP\ 27).c•.� t Ilcarmed contractors fo canetruct the protect (Section 7014. — m❑ hrp❑ ' Business and Profeta ons Code) mu TIE IMBIDeO usE W TIE&xLGIIO ev THe AFPLICNIT oA Furtne aIAIDI W (•f1r++I]= .I.I_ OCCIAMNTrO-0UWEAfFnroTFOHCCHF I=K)Nw Y00mCM1m]N raaYllEeOUTr n r CONSTRUCTION LENDI Ni AGENCY C rAwmmrr amrhlcr MAOM n sax reanmoa aacamr V D �- I he affirm that then le a construction lendrrg sgwK:y for ws❑ No❑ �'� 'JfiL �I,I_I'_I-[I�'�Il Z Performance of the work for which this Permit Is Issued(Sec 3087 Cry C) IFw MAD cleoara TW ucemruooi Y Bo< UNDER TDE� Larders Name COJNT(ComlnTLErwAAoolmwTesuax' wA mFona winmiFaAvaeernnls Lenders Address UYFl1QNOff I certify tha11:" I hne read ibis epMlcatbn and Sete that the above PC FEE PERmrr FEE /��/� J? Information Is correct I agree to Comply with all county / ✓J ordinances end state laws relating to building man and abphereby wmarhtipned property forthorin a tri.cos N f to enter upon /jT -. 3" 1991'"NCE Q .... it-11-4 17""7E�v '1 TOTAL FEE ,1O Sro 3 See RLYERSB FOR EKKAMATORY LANGUAGE