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Home My Public Portal About5111 SERENO DR_Building__ APPLICATION FOR BU_ ILDING PERMIT_ COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BINLDING ADDRESS 1 hereby affirm that I have a certificate of consent to sell Tours BUILDING ADDRESS or a certificate of Workers Compensation Insurance or a certified CITY LP �7 n copy there�800 / �.�. q /� LOCJ`Uiv Policy Noparry T / NO OF BLDGS NOW ON LOT❑ Certif ...� 6 NEAREST CROSS ST ❑ Certified copy a filed with the county building IrepeclKm TRACT BLOCK LOT NO - department USE ZONE MAP NO Date 1=1 4TAPplicart 5`,"� 46— ASSESSOR MPP - PAGE PARCEL '—� � Q lie SPECIAL CONDITION ' CERTIFICATE OF EXEMPTION FROM WORKERS OWE COMPENSATION INSURANCE ` �� reL eWRCN 1000 FT OF SC.I/OOL4 TEs NO (The sectxxl need not be completed If the permit Is for one hundred DISTRICT OROIR TYPE CONST FIRE ZONE PROCESSED BY dollars ($too)o less) � I certify Bet In the performance of the Walk fa which the permit CITY LP �� 0 �F e Baled 1 shall not employ arty person In any manner so as to — J/(i/ become subject to the Workers Compensation Laws ARCl4TECT OR ENGINEER TEL NO STATISTICAL CLA§SFICATION AFT CONDO ca Date App4int ADDRESS - CLASS NO DWELL UMTS NOTICE TO APPLICANT If after making the Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption you should become subject to the Workers TEL NO SET BACK YARD MY PROP LINE WIDTH Canpensatnn Wo nslorm of the Labor Code you must forthwith FRONT comply with such pro*ms or the permit shall be deemed revoked ADDRESS LIC NO P L LICENSED CONTRACTORS DECLARATIONS 6 Of4 SIDE CITY _ LIC CLASS P L I hereby affirm that I am licensed uriderprowg sns of Chapter 9 SEWER j,RAp (comment rg with Seclwn 7000)a1 Dwision 3 of the mess and SO FT SIZE NO OF STORIES NO OF FAMl1E$ } Profesams Code and my license Is m full force aBect NEW ❑ BK PO 'f0 7/ , a Lcense Number ��I—LC Close DESCRIPTION OF WORK ADD ❑ wLUATIp i Q Cmtracto sryrlete ALTER ❑ $ ccV ❑ 1 am exempt under Sec REPAIR ❑ IS BAPC for the reason DEMOL LDMA Pic# �� t +T � W Date USE OF EXISTING BLDG URM ❑ - • Ca � Signature �r % �� -_03 1r1.6iZ � --r APPUCANT(PRINT) TEL NO LOMA farm El as owner of the property or my empfoyees with wages as = 1 ITEMS I their sole compensahm will do the work and the structure a ADDRESS a �IioN L 181 _ 6 not Intended or offered for sale (Section 7044 Business and FINAL DATE Protesslons Code 1 wu Tie rPFrlGv+r m PUTUHE atzROlNo ouzPAxr HANRF A IMZMpC119 AurEraAL I] yI as owner of the property am exclusively contrac6 with m A Wi(TIAE CONDMIa A RALV✓flp19 MATEIM-EOLLAL TO OR ePEATER TIIMI TIECCf`AMplrRs SPECFfiC,par TRE HAZARDOUS MATET4A4IWCIPNAMN OUeE+ FINAL BY >B e ne i cmtractfes to Code)ct the project (Secbm 7044 TEs❑ ru❑ C UE ,QQ E4rslness end Professions Code) `r� I ',01 ;r,c •Y wu TIE urrENOEo usE of TIE suDiiR u TIE AVP1�xr,Oqpt FlRUPG eLackmA , OCCUFMNT PEOIiE A PEflMT Fm CCN3TPl1pTIDN m AKXIFICAIKN FROM TRE BCFOR CONSTRUCTION LENDING AGENCY m�oe�QUALITY MNNDEFENT DISTRICT(C D)fillP!r;m;o uECKLer FOR I hereby affirm that there is a coretructnm lending agency for [I YEs ' Y' N ''�' •a-M^,��, `�' I[Ifl—��__1 ❑ No❑ n the performance of the work for which this permit a Issued(Sec I +I P tOG 1 1 ASI G moi. m - I HAYS REAP THEHAZAGDCU9MATERVI9 PfORMATpN aIODE ARO TIE BCACMD PERMnTNO 3097 CN C) OECKUST I UNOEI18ee1D MY I500FIEAFNIS Lw ER TIE Lae uaEMS CouNTY CODE , Ladder a Name IMTEr1AL.4 RENmI=NO/JIa FOR CaPYlI�Rp A PEfAf =f��^A1 TE Lenders Address r o axon w Amro I certify, that I have read the application and state under penalty of perjury that the above Information IS correct I agree to comply PC FEE PERMIT FEE n / with all county ordinances and State lawn retailing to to trig < a7 Construction and hereby authorize representatives of the County ISSUANCE FEE �/,Q to enter Tpog the aWg mentioned property for impeclan purposes ` 1 NVESfK3AT10N FEE TOTAL FEE eor•a roobr o Ac.. o.. (� SEE REVERSE FOR EXPLANATORY LANGUAGE APPLICATIO;o FOR BUILDING PERMIT COUNTY OF LOS ANGELi6 v BUILD NG AND SAFETY RKER S COMPENSATION DECLARATION T '. .FOR APPLICANT TO Flu IN euILDwG I hereby alfirm that I have a certif"te of consent to self insure ND ADDRESS or a certificate of Nbrkere Compensation knsurerce a a certified copy thej( Xz C O L0 C 1 CRY ZIP ND�1 Cor Wy6 Ik T�1A/D 1 D LOCALITY SIZE OF LOT NO B S NOW ON LOT Certfied copy is hereby fumehed ' �j NEAREST CROSS ST ❑ Certified COPY a filed with the county building Inspection TRACT BLOCK LOT NO department IUSE ZONE MAP NO Date Applcent 5114 ICAA) 014yaj ASSESSOR MIP BOOK PAGE PARCEL 10 --T to I 0 Q I R ` SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS OWNER TEL NO COMPENSATION INSURANCE 1 — IN 1000 FT OF SCHOOL, YES NO (This sector need not be Completed If the permit a for Ona hundred ADDRE / — 7 DISTRICT GROUP CONST FIRE ZONE PROCESSED BY dolens(S 100)or less) I catlfy that in the performance of the work la whch thus pemml _ Is Issued I shall not em any manner so as ro CRY C zw 7v ploy arty, person m A fT OR ENGINEER become subject t0 the Workers Compensation Laws Date Appjoant \It ADDRESS ^^,, s IZ1'�� SWTSIS CUSSIF TILL UNITS � APT CONDO AOTICE TO APPLIC4ATT If after making the Cerbfl08t0 `yy� �T1D T 1 ��(I REOLARED TOTAL SETBFCK FROM EXIST Exemption you ahoUd become subject t0 the NUfkei(1� TEE1 NO SET BACK YARD HWY PROP UNE WIDTH Compensation provisions Of the Labor Gods you must Elfiwrt *3`6 FRONT Comply With such proYl or the permit shall be deerrled re.oked ADDRESS _ uC Np P L LICENSED CONTRACTORS DECLARATION s� LIC CLASS P L I hereby in w that inn 000)o under"B�w� the ..7 SEWER MAP O (Dornlnlernoirlg with Section 7000)DI DNeioSIZE NO OF STOR S NO OFF ES NEW BK PG Q.Professore C de rd my is in full License Number LIC CDESCRIPTION OF WORK ADD ❑ VALUATION Contractor, IU Y-44k J BINAWDate gaw ALTER ❑ $ �d0 A'_'_T.i v ❑ I am exenpl under Sec + REPAIR ❑ $ 3303 171-•�- U BaPC for thin reason DEMOL ❑ _ iy=TEM`- a LOMA P/C• T,r1yj Date 115E of EXISTING BLDG URM ❑ 1.'J,L T T ,i • 'A signature r �y ;r- z r�44.bw-�� APRICAflT(PRTlTI NO LDNM P6rm♦ trp�r� Lu �8�i` ❑ I as Owren of the property or my employees with wages sa N 1 — — _ {y- 1TP Mair sole compensation will do the work and the structure aF �i t_ii tIICI not intended or Al]OR SS offered for sale (Section 7044 Business and am2dia e ss'"ZrA- FINAL DATEQ TSL RafesaorLs Code) wu THE APRIC/J!T on FunuRE etauKO Occuwn IArnDnE A HAZMIpplTS MATERAL1 7 1 Y"I_�i_l i •�m.nH ❑ 1 as Owner Of the property, em exCluarvely contract with OR A MIxTwE DONtUNIND A w.ZMDCUS FWTERAI EQUAL To OR GREATER TIAN THE licensed contractors to Construct the project (Sector 77044 A MIs S iWED ON TIE Hi1ZMDOUS MATERLLLS x OIWKTON OUDEi FINAL BY Business and Professore Code) TEs❑ No❑ NLL THE NTErDED USE CF T11E a1p211e e! TnE AIR)LVR pit nnURE BUILfA OLCUHM REOUPE A FER IA FOR LONSTWICION OA WE PiR T N FROM XU Sg1IH CONSTRUCTION LENDING AGENCY' �UNES r MAx ctr.ENr asrRor IscxoMOl SEE FEnWTTYo oEunusr wit Il�l]I]—Ill_I]1 •_I]i'74 I hereby affirm that there Is a construction lensing agency for TEs❑ No 11 ,N the performance of the Work for wheeh this Permit is Issued(Sec m HRlE IEAD THE HAZAIOOU9 NATERwLSNFDRnAATONaUCE Ann TnE SCTgcEERwrTFo I _ _ a 3087 Civ C) TITLE 2 I UMR 220 ND IAV RE 220 20 100 UNDER TIE LOS ANGELES COLNTr COLE Lander a Name WIEnaLL.9�nEREPORfNpo NID FORaOapUNlp A �n DN T,E No IwZAPDdS Lender Address o I a+.w<n m Nx.r 5� I cerbly Mat I bete read this application and state under penalty PC FEE PERT.ITT FEE S d perjury that the above information a correct I agree to oe ply p Y. w h all County Ordinances aro State laws rate" to building Q h S DOr9tfllLierl and hereby auttionZe represematNes of the OOmlty ISSUANCE FEE g roer won iha a�ore-menbo nd property for I� CO. -- /; •tel' ..i� �S. ,p / INVESTIGATION FEE TOTAL FE� n aavi> rr 7 SEE REVERSE FOR EXPLANATORY LANGUAGE