HomeMy Public PortalAbout5113 SERENO DR_Building__ ' APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES x � BUILDING AND SAFETY
.WORKERS COMPENSATION DECLARATION FOR APPLICANT TO FILL IN • BUILDING ADDRESS
I herebi•afhrm that I ha*e a certificate of consent to self Insure BUILDING ADDRESS
« a certificate of Worker Compensation Insurance or a certified _
copy thereof(Sec 3800 Lab C 1 CITY zm D `
LOCALFF
LI
P�0,11/�y No O am
Cpamy R SIZE OF LOT NO OF BLDG NOW ON LOT
6I Certified copy,Is hereby furnished NEAREST ROSS ST
❑ Certified copy is filed with the county building Inspection TRACT BLOCK LOT NO
'''yt�� I[p/�!y�j (� /� I, ` 1 USE ZONE MPP NO
Dategl / AApp.nt fl V � �\/U/FYf E BOOK PAGE PARCEL
1 O SPECIAL CONgT1C1N8
CERTIFICATE OF EXEMPTION FROM WORKERS OWNER I TEL No `n C�
COMPENSATION INSURANCE 1 N ?S WITHIN n000 FT OF SCHOOL' YES NO
(This sedan need not be Completed d the pe+mrt Is f«one hundred ADORE
pSTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
dollars ($100) or less) — R
I certify that m the peA«maroe d the work for which this permit CN CS ZIP
IS issued I Shall not employ, arty person In any manner,sG as t0 ���� ENGINEER L O
became subject t0 the Workers CamperLseton Laws \ / 1 _ L-. Hl STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ` \nnnn� ADDRESS 1`'Ajo -64
/R'b" CUSS NO Q DWELL UNITS
Al7Ti[`E 70 APPLCANT If after mak]' y
Certificate It LT D ��..� REQUIRED TOTAL SETBACK FROM EXIST
Exemption you Should became sublthe WOfkO T � _� SET BACK YARD HWY PROP LINE WIDTH
CampensatDn provlsxxis OI the Labor Cu must farthvnt FROM
con-#y with each provlsiore«this permit sbedeemed revoked ADDRESS PL
LICENSED CONTRACTORS DATION �j� SLOE
CR LIC CLASS P L
I hereby affirm that I am Licensed urdere of Chapter B TA SEWER MAP }
(camnncrNcirg with Section 7000)Of Drvlsiohe Business end FT SIZE NO STOR S NO OF FAMILIES NEWPG professore Code nd my IDense Is In fun ffect 7. ► ♦== r O
Lxx3nse Numb« Lt COE TAN WORK E "Ot ADD ❑ VALUATION , fi_LT.i C7
Contract« ate ALTER ,❑ $ O
❑ 1 am exempt under Sec REPAIR ❑ $ - 1 ITEM-- F-
BBPC lion tole reason 4 DEMOL ❑ Pic. TTAL QL -I-.11- UJI
a
�/ Date C� USE OF ExISRN6 BLDG
SgretUre/�, ` ICS 24-4-� i APPLICANT raver, NG URM ❑ LDLN Perm. \Jl, n , yNECY. k_IL.�I�I Z
I as ayrpr Of the Property « my employees with wages as �J
their sole Compensation will do the work and the structure isO
not Intended « offered for sale (SCOhon 7044 Business 2E.-2=
S and FINAL DATE 4 Q �i_�.:I'�� q❑CL'.� { ,�f_I r—:t
prd"sucirls Code) 1MLL THE Of` G OR FUTURE BULGING«;LUMNm HANDLE A IMUf OPUS MATEPoAL �, � L � U'JJLI�J?9xm� 1._'r-1• y_
❑ I as ovT r of the property am exclusio,* contrac, With Z�JOR A MIXTURE CCNWMAo A IUSAIpOUs MATERNL EID TO«1 GFEI.TER THAN THE Q
AMOUlIs SPECIFIED ON THE HAZARDCes MATER IWORMATICN GUIDE?
licensed contrad«s to construct the «oleCt (Section 7044 FT"'LL BY > N47rflL 1 2'.1 t:8o
Business and Professions Code) YES❑ No❑ n c_
WLL
THE I141EIi1EG UM OF THE BUpLl1q BY THE ARLC.WI OR FUTME BI.ILW'1 CHECK
OLCUVNfm REQLNE A PERW FOR CONSmRUCTICN CR 1A'YJIFIGTDN FROM THE SOInH _
CONSTRUCTION LENDING AGENCY GUIDELINES AR lTY MAN&EM DSmcT Is D)SEE RER NG CHECKQST FOR O ^
I hereby affirm that Ihere Is a construction herding agency for r^1 _rlt hit -
a the perftt mance of the work for which this permit Is issued(Sec s❑ No❑ V p \ -
m IINVE iEAD TIE IMTEPJN.sPF(AMATIONGIAGE AND THE SCAOMD FEN.•LTN3
3087 DN C) CHECKLIem I UNDERSUV41)MY REQUIREMENTS UNDER THE Los ANGELES COUIJTY COOS
Lerdar S Name ITF-E 2 TEREPORTING2 20 S O2 W 1006 THROiJGH A REwnn 2 WFRO140
TGHEC«DNCEQA�HAZAq[1(x19 I [I J[II I-(Ifll�j 1 6• J J/�T
Lender s Address "Piles 1 AI1 t
I certify that
have read this applicatior, and
tate undw
with aOf llllry that the above counity Ordinances andion Is correct I agree to com State levee srelatag t••/D PC FEE DD. �D PERMIT FEE
construction and hereby authorize representatives of this Caurnt ISSUANCE FEE
"Ithe men netl property f«IrmpecDorn ' r
m / bore- 6• INVESTIGATION FEE TOTAL FEE/1 A
M ARASH o-w O� /�
SEE REVERSE FOR EXPLANATORY LANGUAGE