HomeMy Public PortalAbout5060-5062 1/2 SERENO DR_Miscellaneous__ 1"—'-WORKE MPENSATION DECLARATION 76M444 t -
CE876(1184) MISCELLANEOUS APPLICATION
insure, ayr�of Workaers'Comppemnsation lasurtannca or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sea 3800,Lab C)
Policy No Companyau1LDING. ;
FOR APPLICANT TO FILL IN ADDRESS to 6 a ,SLS Q
Certified copy is hereby furnished BUILDING S 6a $>t EA1 D TgM L CAL1TY T �=-
AOOR[O[ C (� � (� CI r_
Certified Copy is filed with the county building inspection LOCALITY w[ARRST 1c+uC ,
department CROS Sr „
Data Applicant NEAREST /� ,DIeTn(Cr GR TYPE /' PwocxeaeD [r i-
CRO{t BY /y / - CON[TV �/ .�
CERTIFICATE OF EXEMPTION FROM WORKERS' �w � wD `)+Lr
COMPENSATION INSURANCE o 1� r e k6^�2 / P MwRwwr
l<IRCL{I STATE srwroR {[conn LOCAL
(This section need not be completed if the work involved TRAcr C a MOW ON LOTS USE.ona .PEcuL on lore
by the permit u for one hundred dollars ($100) or leis) USE '
SIZE P LOTS t ,� EX 6T MO [LBO
I certify that in the performance of the work for which this
permit is issued, I shall not employ say person many manner OWNER - - s
so as to become subject to the Workers Compensauo aws MEBB -�p t N i A •�'MAIL EBB
OCCUPANCY GROUP
Dat*JAI ` ADDR / L
,A I LUppHCmt
TEL
NOTICE TO APPLICANT If, after making this Certificate of cITT )Q-C D(A NO 8 100 38 _194voOCCUPANT LOAD
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE t r„
Compensation provisions of the Labor Code,you must forth
with comply with such provistons or this permit shall be -`�
deemed revoked. HAILER u{[ ❑ GEOLOGY INar[crlDx❑ No Spec KnoWl
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices
I hereby affirm that I am licensed under provisions of Chapter swPRrr P[auIT ❑ (Liar IT[sr•a[I.oir) el
9 (commenting with Section 7000) of Division 3 of the Busy NO OF EXITS C,
essseffeand Professions Code,and my license u m full force and �� T d 7 E� r 19
SPACES RHO'D = PROVIDES r M
License Number L'c Class TI Z¢'9 SI — LIMITED TIME USE Y_
Contractor Date A2DM t- 1141 00M V 71JO C R
awT{ Dwr{
I am exempt from the hcens n requirements as I am a R j it 1 - .D IN PECTow•a T
licensed architect or a registered pruft+satonal engineer Six[of No ow
EXISTING BLDG {TORI[{ SIGNATURE
stung m my professional capatity (Section 7051, Bus• _
Mess and Profeauom Coda)
PR E{i NT Uei OF GUILD INO ' FINAL APPR O >>
Lnc or Reg No Date �) -'
HOME OWNER-BUILDER DECLARATION na OF EXISTING DUILDINOB �/) �y � ,T
Gn LOT AMD USE rVF sf F/{ r/
I hereby affirm that I am exempt from the Contractors /t, 1 I•-'�,- --
License Law for the following reason (Section 70315, Burr IV I Tr
'\ TOTAL ness and Professions Code) NO PARKING �� 3C 5C
{PACBS PROVIOEO
�I, uc owner of the property, will re the work and the PECK ?f,�l
structure u not intended or offered for sale (Section +C� �(\�� l .1`
7044,Business and Professions Code) + v t 7 �,) (Lw y�f'�
CONSTRUCTION LENDING AGENCY
PROPOSED DSC OF BUILDING 'slJ Inyy�_ 1
h�FCO R TL j
I hereby affum that there Is a construction lending agency �� �L \ �1 1 (�,1_IL;1_+[h7 J1rE9
for the performance of the work for which this perrmt v
Issued(Sec 3097,Cw C) I/ v7� 1 SIM KI ";It
Lenders Name 1 y
PwOPoe6B MAX Dec t�
Lender's Address � \ yV1ry-ulr D
PER IT FEE VU
( certify that I have read this application and state that the
'hove Information is correct I agree to comply with all County ISSUANCE FEE l
ardmances and State laws relating to building construction,
Ind hereby authorize representatives of this County to enter TOTAL FEE
ipon the above-mentioned property for rnspectr purposes tl \tt\\v\
J Jj �� f �Z !$ SEE REVERSE FOR EXPLANATORY LANGUAGE
/�Signature of Permittee Date