HomeMy Public PortalAbout5078 SERENO DR_Building__ APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKS"COMPENSATION DECLARATION FOR APPUCANT TO FILL IN B111L3ING
Ihesby dorm dust 1 hwe a certificate Of consent to WH kinins, BUILDING — O E
w a oartlflcate d Nbrkera'Compensation Insurance w a certified DR
�, 23Pcopy tiroreof(Seo 31100,Lab C)
L
Pollry company &ZE L FW OF SLOGS NOW ON LOT
❑ C m
Iffied copy s hereby fushed �x I NEARESTCROSS \
13InspectionCT Cerafled copy Is filed with the county building Inspection TRABLOCK LOT NO
I^ 119E]:Ott MAP NO
Dela Applicant WASSESSOR MAP BOOK RAGE r PARCEL SPECIAL CONORIONS
CERTIFICATE OF EIEMPTION FROM WORKERS' O OWNER TEL.NO I T YES
COMPENSATION INSURANCE - (T WITHIN 1000 FT OF SCMOLT
0his eection need not be completed H the permit is for one hundred � p � //(g SS`�-zy $S 01.4fA1CT OROl1P TYPE CONST FIREZONE BY
dollars($10D)or lees) C A �A7 P
I OK*thin In the performance of the work for which SW penult � RE /IR rJP //� �.� /1'3
b issued, I e1W1 not employ any person In any manner w as to CT OR ENGINEER TEL NO
become eutm(ect to the Yorkers Compensation L2 `� ORPa 9'TATISTICAL CLASSIFICATION APT CONDO
Date Applicant J` AVE /(� MASS NO al DWELL MrTs
NOTICE TO APPLICANT tf after making this Cperliftete of NEZ REQUIRED TOTAL SETBACK FROM BUST
Exemption, you should become subject to the Workers' - TEL NO SETBACK YARD HWY PROP LIRE WIDTH
Compensation provisions of the Labor Coda you mud forthwlth COftTRACT011 S U nW
comply with such provisions or this permit Mall be deemed revoked v uC I/O P� _
V O Z SIDE >
LICENSED CONTRACTORS DECLARATION CITY LIc a
0 SE p
I Omme affirm thin I em licensed under pro of 0,B Chapter 8 LL_ FT OF ST NO OF RIES .r m
(commenang with Section 7000) S Dmabn 3 d the Bnakess end H
Professions Cade,and my I b m rot force and elfeLt NEW lq BK Pct 307 652.13
ON Of WORK
License Wlrmher �S>Llo Gess 13 ADD ❑ 1 ITEMS
YAIUATION W
Contractor Data ONAE QoE F1 VE 4=1 ,gLT�p ❑ $ $� �l13.60—LIVI Cs OD 46;A TOTAL 652. 13=
•
❑ I am exempt Mulder sea REPAIR ❑ ; L CFEq( 682.13
BBPC for this reason DEMOL ❑
Defer 119E OF EXISTING BLDG - URM ❑ LOW P/C• l fbD a .011
Sigriature
❑ I as OVR err of the property er my employees with wages.a MUM/ 6 8 .) OD LRLN P.n e WOO—=1 3/ 1/90
their w1s atl
comperson wwork ill do the end the abucWre b AooaEss �/r '
not inlended or oflored for ode (Sectloin 7044, BBeiness and ° NO # FDUL D�,nZ ` j I O •* 1 AM 10145
ProteWone Code) WILLT1EAiR1CINraRMIM1aW.eM000Q1fw1?HAMOLEAHVMOW9WRBWL (p J 3307 824.64
❑ I 88 Owner OI the property, erne sacci OR A MU CprdMMo A IrAAlRaanm YR6aAL®UAL TO M oia AM TWIN +
YCefeed contractors to oonstnrct the COcCting with raAYdxResPEGF®ol ralLALlmiOeA}mwFaua nsoarAnnoN OU�i! FUML BY IJ
1 ITEMS
pmoJeLY (Section Toa, ,es❑ w❑ �7 TOTAL 324 . 64
Business and Professions Code)
WILL TIE eiETIO®119E SIF TIE BIRLwrO BY TIE APPLICNlr dl FlIR12 auunlNo _ )
OCCUwNTIQ-011aEAPEiYaT TOR COHHIR MCAOMD)SEEOAT10MF110MraaIXI1N 1
CONSTRUCTION LENDING AGENCY � Rouurrr"-a,::a-osmmocT Iarwoml ass reamTMo aeuur I I CHECK 824.64
I hereby allmn that there Is a conebuolon landing agency for
the parlomsmmce wttich of the work for this permit is lowed(Sec Hwle RaAp T OHArARoorm IwT�wa srawLammaN orno¢Aro ra eu�aro D /A \ r OE .OI]
3087 CIV C) marrntn aEoanar I nAVOFRATNO w IEouomwrrs uar11 ra Los wo¢® y/."I'••:
Lerda/a Nene r�m ioAawR,aerA leen Arvnarra �"O/ _ 0000-0001 7/20/91
I Ow*tAadress
hav 1957 1 AN10:45
I forma thin 1 bars lead this a agree
to
m slate that the ebnty PC FEE ^. 13pgaaT FEE
thfonmation n oa lt)JA I agree to comply with all county Q
ordllenoss end Stele laws retailing ro building corWrnrcaon,and
hereby2511 . L
autll�f¢e��fesentad a of this County to enter Upon ISSUANCE FEE �3
rtY f«Inspection purposes
R �^ I eO NJE9TIGATION FEE TOTAL FEE
d a mr
BEE REVERSE FOR EKPLANATORY LANOUAGIE
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TOFILL IN BLALDINGADDRESS
I hereby affirm that I have a cerbfirate of consent to safi Insure . tz . 614 _ —�L7/
or a certificate d Wbrkm Compermabon insurance,or a certifies '56w
'Na
Owed ISM 3800 Lab C) cTiY • 11PLOCALITY f�LG
Policy No Company Sad LOT OF BLDGB.NOW ON LOT
❑ Certfilatl copy Is hereby fumfehetl ir NEAREST CROSS ST
❑ Cartirbtl CON Is Bled with the county WON Inspection TPACT BLOCK LOT NO USE ZONE MAPNO
daper6nerlt
Date Applicant_ ASSESSOR MAP BOOK PAGE PARCEL SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS' TEL�
� YES
No
COMPENSATION INSURANCE Sibtl1 rbbD scHooL7
ADDRESS
(Thio aeC00 need n )b0 compktetl tithe permit bfOf 0118 hundred �. V D GROUP TYPE FIflEZONE ��
1Wea,x7100)or hem) n 3
I arty that m the penformallce d the work for which this parmrt cl7'Y ow nP K
Is Wei I shall not employ any person n arty man w m to OR ENGINEER 'TFL NO �
boat the Nbrkaa' Lawn CLASS
LASS NO WE
APT CQNDO
p�Applicant ADDRESS CJ.A SNO DV/ELL UNRB X
ROTI TO APPLICANT If p this Certificate Of REOUIRED TOTAL SETBACK FROM EXIST
Exemption you Should booO B Mn sot t0 the Workers TEL SETBACK YARD MW PROP UNE WIDTH
Compensation prorbnons d the Labor Cotle,YOU must fortllwlM
comfy,with Such Provisions or this permn shall be doerre0 revoked LID NO
PLO
DE
LICENSED CONTRACTORS DECLARATION or /z V c v 1.
I hereby eflfrrrl Thal I em Ilcsnaed under provmione Of Chapter B v' �a-�•-� G -74
MAP Ca
(conlurienci lg with Section 1000)d Division 3 d in
the Business anti so FT SIZE NO OF STORE9 w OF FAMILM5 NEW BK PO ? ITEM; F
Proteeslons Code,and my I n tush force c:
D PTIONOFWORK ADD ❑ VALUATION ,!"td_ 11� . ot7n
Licetem Number Clam D C j
_ .CEet ALTER ❑ S ®v(7 '_Flt % i��..t'z
❑ hemFth
Sec / REPAIR ❑ S •I-I-
B Ceeaon DEMOL ❑ L.DMA PIC a _
Data USE OFEKISnNGFu URM ❑ LFJJU-3&D1 VAI/q�'�'��_
Signature TEL LDI1A Pa 19 a�iL 1 AM a':,:
❑ I, as owner of the propertyy, or my employees was wages as - t
their Soo compensation,Will do the wort and the structure is
not Intended Or offered for cob (Section 7044 Business anti
Prdesegns Cade) wnr_rneArvucwroswnAm auanegocwrwNr ANArAAoanwTeraAi
❑ I n owner d the am exclusively ort A rxnrwa canrNr to A HATAflDdm EauAL ro oR olmaw TH,w y ITE 7"
licensed! conbacton COnStrICt the (Se 7p41 mM1oIAlre al+rslrD CN TNe 1UTAIOOIA niowlAnw ataoET FINAL aV/�%/A �_ > _r' c qc
❑ Iq❑ d ti" 1-... 1 a
Bnmmem and ProteaUonm Code) wsy Tale ortdOm ueE aF THE 9UILo1eo c THE APRJG1fr Oa rurtme wawKl ,J _-
Ooi] AIT QuAuTVAPBYQlfgllComlPUCT10110P NpgFICArgNnKw ci aOUrM L✓a=.f\ IC..`•
CONSTRUCTION LENDING AGENCY m_l An aunuTr MANAOEemrr nsrRlcr Iw,m.m tiff PeSrrrS1O acON.mr
I hereby affirm that there m a construction lendalp agency for res w❑ ❑
the perfomlancs d the wort for which ti1a pmmd m beued(SSG I Iuee nmAO Tlm IwARogs w ul vroralATloe Dams AIID TRE atom ll}} ,r�� }
3087 Cil, C) NFinaTTINo Gaaaar l urauswl =I... urn l)91 rIm LOe ANOEIEe f J� ]4.H_I L 1"/aY/
Lenders Name cone Trrlasawrraea c nw oNs r 1 ti
Lenders Address e �'r7d 1 ' AM L;7_
ICorby that 1 have read this application mid date that the above D
ntorrrlatlon m correct I agree to comply with all countPC FEE PEJW rt FEE y 3ipi I
ordinances and State Iawm rabmlg to bulltling construction end
heaby adhorlm repras nnodyes of BIB County 10 anter upon tSSUANCE FEE /
thea am4noint"property'or Inspection P ossa���TTT
R A ` PNKi
ESTAT10N FEE TOTAL Fly