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Home My Public Portal About5105 SERENO DR_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 675 (11 8G) MISCELLANEOUS APPLICI4TION {1 CE 875 L1 I hereby affirm that I have a certificate of consent to sellj insure, or a certificateo£Workers Compensation Insurance,or -COUNTY-OF LOS ANGELES "BUILDING AND SAFETY DIVISION a certified copy thereof(Sec 3800,Lab C) ' Policy No Company FOR APPLICANT TO FILL IN BUILDING /O� ❑ ADDRH sB Certified copy u hereby furnished ......O O p=k1=JJ0 � TrM ME C� AUILDIN JJ�V LOCALITY 0 ElCertified copy is filed with the county building inspection LOCALITY NEAR eer department R. aT Date Applicant NawRQaT DISTRICT NO our rYPE CeasED BY CR088 8T I'VeCONS CERTIFICATE OF EXEMPTION FROM WORKERS LEGAL =:07,0d COMPENSATION INSURANCE BE IPTION LOT NO BLOCK 1..ww srwre MAJOR aecorvo LOCAL NOWOK LOT rI'I. lural _ (This section need not be completed d the work involved rrwcT Now ox LOT USE zorve SPE LCONDITIONS by the permit n for one hundred dollars (2100) or less) I urE or I certify that in the performance of the work for which this 811E OF LOT a .TING BLDG o permit u issued, I shall not employ any person in any manner owxeR C A S e Ao—sha'" vxa Ki as to become sub ect to the Workers Com ensation Laws OC j p MALL e L ��r OCCUPANCY GROUP o A DOR HSS r' L LT Date Apphcant NOTICE TO APPLICANT If, after making this Certificate of CITY sp 'NOL 8/r7 y-� 066 OCCUPANT LOAD Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forth APPLICATION FOR EXIT HARDWARE with comply with'such provisions or this permit shall be TRAILER USE GEOLOGY INsr HCTIOry deemed revoked ❑ ❑ No Spec Knowl =i1 LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ Panic Devices Alf i I hereby affirm that I am licensed under provisions of Chapter �+ SAFETY PERMIT9 (commencing with Section 7000) of Division 3 of the Bust- ❑ (LIST ITEMS BELOW) NO or WITS — ness and Professions Code, and my license is in full force and effect PARKINGREDO rROVI SPACE. CCa _ License Number Lic Class LIMITED TIME Contractor Date AT. oArR 't.4' ❑ I am exempt from the licensing requirements as I am a FROM TO L14Af41 licensed architect or a registered professional engineer Biz¢or IN.PECYOR S STORIES SIGN/ acting in my professional capacity (Section 7051, Bus- EXISTING BLDG NODr un¢ mess and Professions Code) 1 Lic or Reg No Date PRESENT u H Or BUILDING FINAL APPROVAL6 f7/ HOME OWNER-BUILDER DECLARATION No OF EXISTING BUILDINGS Q ON Lor AND uEH I hereby affirm that 1 am exempt from the Contractor's G License Law for the following reason (Section 7031 5, Bust- ness and Professions Code) NO PARKING 1, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section - 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOS USK Or BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec 3097,Cry C) Lender s Name PROPOSED MAX OCC Lender's Address r lir PERMIT FEE I certify that I have read this apphctnon and state that the above information is correct 1 agree to comply with all County ISSUANCE IEE �,- ordinances and State laws relating to building construction, 7 and hereby authorize representatives of this County to enter TOTAL FEE pL3 upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o e mittee Date