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Home My Public Portal About5043 SERENO DR_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKERS COMPENSATION DECLAMATION FOR APPUCANT TO FILL IN SWI-DING ADDRESS I hereby affirm that I have a certlncats of consent to Dan Insure S1aLDlnO ADDRESS «a cKlificato of workers'Compensation Insurance.or a cernnetl O JC2 dr 5 �' copy thereof(Pec 9800 Lab C OTvT aP r / ITZ5L polic'Ne COn 'I' ^^•� SIZE OF LOT NO OFBLDGSNOWDNLOT PLL- I ❑ Cartifled copy Is hereby fumshsd I NEAREST CROSS ST �CortnMd copy is filed with the county bu0ding Inspection TRACT BLOCK LOT NO ��—�/� �P USE ZONE DMP NO �4 a 1 „p,I� � )11 t AESE d�°°K PMF, EARCESPECML CONDITIONS/ 0?l~5 CERTIFICATE OF EXEMPTION FROM WORKERS' �( VV'' ��d` O ,J�` COMPENSATION INSURANCE "` P —Iy� FT ND (This settlor need not be completatl n the permit Is for one hundred A'm Icy o a CONST R Sy dollars($100)or less) 1 certify mm in the performance or the work f«which thla pertnttl V41 LC �,. (/ la Issued I shell not employ any person In any m rmer so es b ARCH OIt ENGINEER TEL Np Gil` U(lJ� become eNb(ect to the Nbnkere Compax on Lave. Vit '� r, STAT44TICAL CLLASSIFl�GnON Data Applicant t�\T� ADDRESS CLAW NO �� / DWELL UNITS NOTICE TO APPLICANT If alter making this Caniicet, of `� A Ag� '— &CML RED11stED TOTAL tlkfEACK FROM EXIST Exemption you should became aub)sC[ to the Workers u1 a Tit �_ SETBACK YARD MVY PROP LINE N'IDTN Conversation provisions of the labor Code t (1 oompy with such prwslons or the pean shell bautl a rled neyokeo �7 ADDRt e I n I uC —' PL PL ' DRT SIDE CONTRACTORS DECLARATION O t 1O Pt. 1 hereby afMln thet I am licensed lander provisions of Chapter all FT NO OF STORES OF PAMLIE9 SEWER AGAP �'� tr (oommencirg with Section 70D0)of DNlebn 9 of the BuW*r*m a and _ fiofeeebrs Code I m in full force and onset J7AI NEW BK Po ACCT.: Lloenee Number I Uc Class U�DESM�N OF WORK A ADD V LI J,]D7 77�.i�2 li DS Convector NaI a e�L:I.�eyjl i ft \ ALTER ❑ s F) 1ITOS z ❑ 1 am exempt under Sec REPAIR ❑ s 'y; DOG• 6-O TO1�T�AyL 772 - 02 B BPC for Oft reason USE OF EXISTING N DO. DEMOL ❑ LOMA Pro# MCK 772.1.' Date `� URM ❑ pot .DD ^� a `J "W" TEL N°—1)) LDMA P.m# _ ❑ I. ee owner of the property, or my employees with wages as L� ' O '- their sob compensation will do the work and the structs is % ADDRESS L q I 1 1 A not Intended or offered t«eats (SO= lou, BueNsss end\ FnfALDAre CIDDD-LD1 3�i3%9C Professions Code) I VIILTEAPR1CAMidlrunaaall¢neuocaaWnrwwaYAIMTMIa011a WTBIIAL L A i AM 11 u i 11I, ere owner 01 the property. am exclushely contractln with A YMURE ooaowlo A HAlAneOVa NA.vaAL eouAL TO oR onATm THAN — `• �-- - 9` i o TICAYOI#1}e erecnnm oN THY NA:AnmoIls NArv+wausorw,vnoN auger FisiAL By licensed Busi nese Professiooni s Code) the protect (Section lou re.,❑ No❑ (• " S h �?C l�_�. vaLL TE MQaI®U®«ll!auww er M APPInCAIR On Rn111£ellaa#Ki i CONSTRUCTION LENDING AGENCY oTCWer Am aAurrA F°iTm�NerracnoNAMSE rwn°"`nwTlc°u"" 1 �tM� IecA01m)off rEReRTalo o¢Iam wRAumeL,Fa �p '`p 1 , DOTAL 1;°E.,1 I hereby d&m dust there b■construction permit Is agency( for �.Ey❑ �❑ L the Civ C)nncs of the work f«which Dae permit b marled(sec �) (� C HE(, 9087 CNC) I wrY wit TIE HA7ARpp19 uvalula aaonlATlaN puree AW T�ens e re.mTan Oa3paim I ua�sovo rr ro�uomuTnn umm r�l.ce ANoun - - 5 Lender's Name ^' T�� sucrn«munmomnowHa�nacaNcuaeno HATAIOOI1BNRwVALa 11tPOmaIa AHD WN ra1M1-01K/A PFA111T FlaIMTIleCA01O Lender's Atldleee 11aa1.VDlr e 1 ce"that I have reed this applicatlon and state that the above A$ Pc FEE PERMrr Cli DAF—C41C11 11i',.1P infmmabon le correct I agree to comply with all county ordinances and stab Tawe relaft to Wilding co ndr,cna,,and 10,17 hereby authorize repreoentedves of this Coumy to enter uponthe abovemandoned - �. property for hppsCngnypa 1p INVESTIGATION 7 FEE TOTAL �`+/ BEC REVERS!FOR EXPLANATORY L Auer AAMC L WORKERS COMPENSATION DECLARATION I-hereby affirm' that I hove a certificate of consent to self 1 insure, or a certificate of Workers' Compensation Insurance, APPLICATION-FOR BUILDING PERMIT or o certified copy thereof (Sec 38OQ Lab C ) _ t COUNTY OF LOS ANGELES _ BUILDING AND SAFETY Policy No4k9- Sn2kompony - ® ,Certified copy is hereby furnished - FOR APPLICANT TO FILL INqqNiAP �pRESS ❑r Certified copy is filed with the county budding inspec- - — �REu titionddepartmentDate��ApptiCant Ory ZIPLOCALITYr FBLDGSNEAREST - CERTIFICATE OF FROM WORKERS' SIZE OF LOT 1j4 ZC:IO NOW ON LOT" CROSS 57 •COMPENSATION INSURANCE CRo cESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NBOOK �j O PAGE Oleg, PARCELe/ hundred dollars ($100) or leu ) - ' OWNER O C _ p t _ USE ZONE P I certify that in the performance of the work for which this _ �/ SPECIAL r' Y IAL permit is issued, I shall not employ any person in any manner ADDRESS �A - - -_f k-,,7 CONDITIONS d so m to become subject to the Workers Compensation Laws - _ O _ - CITY C� - It, " Date Applicant - ARCHITECT TELOC -NOTICE TO APPLICANT If, after making this Certificate of . ENGINEER NO 1 _DISTRICT I GROUP ITYPE FIRE SSED BV O Exemption, you should become subject to the Workers Z Compensation provisions of the Labor Code you must forth- ADDRESS - with comply with such provisions or this permit shall be TEL STA715TIG4L CLASSIFICATION APT CONDO LO .deemed revoked CONTRACTOR : NO I - 1 z LICENSED CONTRACTORS DECLARATION LIC CUSS NO DWELL UNITS_ I here affirm that I am licensed under ADDRESS - NO O SEWER MAP by pion 3o f of Chapter s - UC (commencing with Section 7000)of Division 3 of the Business CITY CLASS 3K PG VALIDATION and Professions Code and my license la in full face and effect 50 FT NO OF NO OF CHECK License Number 60gQ3 L¢ Class SIZE STORIES FAMILIES ONE ' - C - VALUATION Contractor ` I Data -132 DESCRIPTION OF WORK NEW ADO ❑ , ❑I am exempt under Sec ❑ ' ALTER B 8P C for this reason REPAIR ❑ $ Date USE OF EXISTING - `- - 'DEMOL ❑ Signature _ APFLICANT _ - TEL FINAL - O ER-BUILDER DECLARATION .(PRINT) NO DATE I hereby affirm t at I am exempt from the Contractor s License _ _ Law for the following reason (Section 7031 5, Business and ADDRESS FINAL - Professions Code) _ I - ESENT BY ❑ 1, ce owner of thero BUILDING - - p party, or my employees with ADDRESS i. wages as thou sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Profession's Code ) MOVING _.TEL , -'f- ' ❑ I as owner of the property, am exclusively contracting CONTRACTOR NO -- _ - -'r•_ v -a with licensed contractors to construct the project (Sec- tion CONSTRUCTION LENDING AGENCY ADDRESS _4 _- 7044, Business and Profeulons Code) REQUIRED YARD HWY TOTAL SETBACK FROMEXIST- MET BA LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P1 (Sec 3097, Cry C ) SIDE , y PL _ _ Lender's Name I-t- -I��1 1 -_ '_ . . �� LDMA Ref N Lender's Address PC Fee sI Permit Fee - - - - 2 - ►o I comfy that I Bove read this application and state that the Issuance Fee LDMA P/C 0 t above mformation is correct I agree to comply with all County Inveregonon Fee ordinances and State laws relatmq to budding construction total Fee LDMA Perm N a and hereby authorize representatives of this County to enter - 1Y9 upon the above-mentioned property/�rf° ontpection purposes ��S_ _ ✓LT SER REVERIE FOR EXPLANATORY LANGUAGE. grwture of Applicant or Agent Date - -