HomeMy Public PortalAbout5044 SERENO DR_Building__ WORKERS COMPENSATION GECLARATION� II ' 1 7 .
i insure
boaffcar orate of
certificate of amen, to%self I o � APPLICATION FOR BUILD PERMIT
Il -
iruure or a cM�fimre of Workers'Compensation ImuTance, yl
or ceq�OGL y ereofjSec 3800, Lob
O- /v d 3- � COUNTY OF LOS ANGELES e , „B SAFETY 0
P icy �
No mpany
❑ Certified copy is hereby turn,, ad (CANT TO FILL IN BUILDING
ADDRESS
died copy is filed with the county budding mspec
tion deportment ADDRESS LOCALITY
NEAREST
Date Appbccnt I CITY ZIP CROSS ST 01J
CERTIFICATE OF EXEMPTION FROM WORKERS' I NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT �� NOW ON LOT MAP BOOK I PAGE PARCEL
(Thr section need not be completed if the permit is for one 3 USE ZONEI MAP
hundred dollars ($100)or less ) TRACT BLOCK T NO NO
i - �eZ SPECIAL �
I certify that in the performance of the work for which this OWNER CONDITIONS Q.
permit is issued, I shall not employ any person in any manner - I DISTRICTGRWP TYPE FIRE D Y O
so as to become subject to the Workers'Compensation Laws ADDRESS Sof CONST Z0 V
3
Date Applicant CITY ZIP STATISTICAL CL4551FKATION OND0 iO
NOTICE TO APPLICANT If, after making this Certificate of ARCHITECT OR TEL 3
Exemption, you should become subject to the Worker ENGINEER NO CLASS NO 03 DWELL UNITS_ 1
Compensation provisions of the Labor Code you must forth ADDRESS - - SEWER MAP Z
with comply with such provisions or this permit shall be TEL M Q ypL10ATION
deemed revoked CONTRACT - AI
LICENSED CONTRACTORS DECLARATION T
I hereby offum that I am licensed under provisions of Chapter 9 ADDRESS C VALUATION
(commencing with Sectsion
ns 7000)of Division 3 of the B nines and LIC /� ®0 0 ;I z „ /{
ProfeioCode, and my license is in full force and effect CITY CLASS f 2 Z�
SO NO OF NO OF C ► !' w 4 e a ?3
(Con
Licens Num r ClainSIZE STORIES FAMILIES ONES • 0 � A7 ?
tractor Date ?,--j
� OFSfRIPT10N OF WORK 1 _
❑ I am exempt under Sec I ,�\ _ \ p 7 1 9 - 54
ADD 6 T
\' ALTER ❑ FINAIs7
B&P C for this reason Ri I REPAIR ❑ DATE` —�
Dote USE OF ❑
EXISTING BLDG By
Signature APPLICANT TEL ?b A
OWNER-BUILDER DECLARATION INT (!V NO 3 T
I hereby affirm that I am exempt from the Contractor s License
Low for the following reason (Section 7031 5, Business and ADDRESS
Profession Code) WNI
❑ BUILDING
1 as owner of the property, or my employees with ADDRESS
wages compensation,will do the work and LOCALITY - , '� ' >�i 0 J v
suis as thou sole
the structure Is not intended or offered for sale(Section t�f
704 Business and Professions Code) MOVING TEL - t •' . (' 7 17•_ (i
❑ I,as owner of the property am exclusively contracting ICONTRACTOR NO
with licensed contractors to construct the project (Sec- ADDRESS
tion 7041, Business and Professions Code)
�uIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SEr BACK YARD HWY PROP LIN WIDTH i
t hereby affam that there n a construction which t lending agency for FROM ,
the performance of the work for which thn permit is issued P S. 07 t.1 O
15ec 3097, Gv C ) SIDE Y -
e PL -
3 Lenders Name /'�,//�``�( PC'Fes S I` l Permit Fee 1,3`34,
Lenders Address I _ rL '.n, 31'�• 'ri S.PY^06 LOS
I"certify that I have read tl9a application and state that the .�* O Issuance Fee 0v ,
above information a correct 11 agree to comply with all County Invsgipmion Fee JS-
_
`
ordinances and State Iowa Ablating to building construction, Total Fee mcJ i
andJ�;.uthorizer ntabves of this County ante j
u e-msnho operty for inspection
k L fE!ItEV9tfE FOR EXPLANATORY LANGUAGE
of Applicant or Agent j Es
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