HomeMy Public PortalAbout5235 SERENO DR_Building__ ✓ ' APPLICATION_ FOR BU_I_LDING PERMIT
• COUNTY OF LOS ANGELES _'BUILDING'AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADORE /
I hereby affirm that 1 have a certificate of consent to self Insure BUI NKI ADDRESS
or a certificate of Workers Compensation Insurance or a certifiedZ 5F O Sr 2
copy thereof (Sec 38 La C) CITY ZIP
T•� -CE+A 'T LOCALITY 01
Policy No' Pony 1/ EVE OF LO NO OF BLDGS NOW ON LOT
❑ Certified copy e v f r /—/—tel (. $Q Zai 5VF 1 NEAREs cRoss s
❑ Certified copy s filed with the county burg inspection TRACT BLOCK LOT NO
d¢�p--gJg�ggit/j�y USE ZONE MAP
Dale M1/ If�,J'Jj-,K Applicant ' ASSESSOR PAGF�/ PAR
{ •V V C� SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WOR RS' R ✓ TEL L
COMPENSATION INSURANCE _ t1 1 TH U I{ oo FT OF SCHOOL? YES NO
(This section need not be completed If the permit s for one hu ADDRESS '
dollars($100)or less) Oe, t � V fr-- ) CT GROUP TYPE CONST FlRE ZONE PROCESSED BY
I certify that In the'performance Of the oak for whioh the permit crry LP O [/A. L —
s Issued I shall not employ any person In any manner so as t0 W OR ENGINEER
N NOI O ��O -
Uecarrp subject t0 the Workers Canpen98tion Leve I ' / SV,TISTICAL CLASSFI�PTION APT CONDO
Date Applicant ADDRE - Ob CLASS NO DA'ELL UNITS
Ab77CE TO APPLICANT If after making the Certificate of to A- REQUIRED TOTAL SETBACK FROM EMST
Exemption you should become subject t0 the Workers TeLffo SET BACK YARD HWY PROP LINE WIDTH i
Compensation Provsrors Of the Labor Code you must tatlNvrth
Comply vnth such provssrs a the permit shall be deemed revoked ADDRESS LIC NO IL
ST
LICENSED CONTRACTORS DECLARATION O O ' SIDE 1
PIL
I herebyaffirm that I am licensed undo CITE) LIC SE
rMOY6,Ors Ot Chapter 8 G L/ SEWER MAP
(commenprg with Section 7000)of Dwsion 3 of the Business and SO FT SIZE NO OFF STORIES NO OF FAMILIES l'
Professwrtv Cod pnd I s In full force and effect ' �j Z 1 NEW BK PQ ��lh i }
License Number K� Lac Class V.bRK ADD ❑ w1LURRON i , 1 ITEti` ,IRI 110
�Contractor ,(,yO_� Date 4J �s �` ALTER $ L/, 400 O r NIZIL J _ O
1�V�..1
❑ I em exempt unser Sac A REPAIR ❑ $ CHEC t.
BSPC for the reason `r MOL ❑ 131
Data Q U:2f
E of (IS➢NO BLDG UR ❑ LDMA PTC r'
Signaturez
w (PRINT) TEL hJ0 Lp.N Perm♦ • , Or - Z
❑ as owner of the property or my employees with wages as h.1 U - �` /'- Z r
their sole compensation will do the work and the structures ADDPES _ -O �hT
not Intended Or offered to sale (Section 7044 Business a 1 U W 4V DATE ";-� J 1,\ N `1` 1
Professions Code) Yt THE N=Flxlxn OR FUTURE WLD1 H NE A HA zu oa s A EwA a 1 ITEMS
❑ 88 OWnBr Of Tile property air a%C UBNBIy Conti with OR A MIX g dFlE aV THE HAWioae WTERIle EOLML TO CilicenspLpETER T1Wl TE FINAL BY j
Business
conand Professions
to Co cIaact the pmlecl ( 7044 YEs❑ Na❑ TOTAL 1684.5,3
Business and Professions Code)
wu THE INrENoeo usE on rrE eupLNO ar THE u*Tucwvr a9 FUTUE Blatwp
oOAST R rEaulrE A PERMm FOR eoRICT( MO ore ME PERMT-N G PE sour C HELY 1584.los
CONSTRUCTION LENDIN ENCY coAsr NR auAurY"• .OEC osrwcr lscnoMOl sEE RERMmnNa aEc%usr FOR C HAN(>E .
00
oumE LEs
herby affirm that there Is a cone on IBfAI'InIQ agency for rEs❑ Np❑
the performance of the work for this permit s issued(Sec
IHNrE READTlE,NZupa13 MATEPJM9 rFORMATKIN aA1E Mio lHE SCAD.•Di£RMmmNe v/ 0000-0001 5/19/95
ry 3OB7 CN C) CHEGa18T I UNDERmMp MY REOLiEMEM9 CINDER THE LOS MleELES COUMY CODE
Lenders Ndnrle VATEWALS vETEPamw,yp FOR peP1rAN0 A PERMOn Fight MAOMc O HAZIPDW9
Lender Address 05011 AM 9:57
o anon w rurvr
I certify that I ha read this application and state under penalty
8 of perjury that t above Information Is correct I agree to comply PC FEE PERMIT FEE /���
with all county orduances and State levee relating to tudding s,f `
corsfrucfran and hereby authorize representatives of the County 4SSUMCE FEE �j/ n`
to enter upon aboee nlentio property for,speetion Of 6 GJ
INVESTIGATION FEE TOTAL FEE /
SEE REVERSE FOR EXPLANATORY LANGUAGE
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES a BUILDING AND SAFETY
WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN a1aLallo ADDITEss p r ,
I hereby, affirm that I have a certrfK:ete of consent to Self Insure
Nora E
a certificate of Workers Copenseten Insurance or a certified
copy thereof(Sec 3.8,00 Lab C) 1� C; Zip
Policy No►UCN/�+Fo si Company h Lo r D �w Locwrry t _
SIZE OF LOT NO OF SLOGS.NOW ON LOT
❑ Certified copy is hereby furnished NEAREST CROSS ST
❑ Certified copy us filed with the county building inspection TRACT BLOCK LOT NO
department - ^- Tn T ,.-�/ 115E ZONE MAP NO
Date 47/ Aw.nt FID tml 1 "c iUI• �S �rp PAGE / cwRC%�NO ���JJJ
Q (J (I _�+ SPECIAL CONDITIONS
CERTIFICATE OF EXEMPTION FROM WORKERS °W�RIii VA4410.Xh1 Ilft(I X17 " YES No
COMPENSATION INSURANCE WfTHIN toxo Fr of SCIi00L7 ,
(This section need not be completed If the permit is for one hundred AOOFtE 6 �.r.a-t
DISTRICT GROUP TYPE CONST FIRE ZONE PROCESSED BY
dollars ($100)or legs) A
I certify, that In the Performance of the work for which Mm permit CTry T IL 4 Z� q 1-7 9 0 ' .3`oP /P•3
b Issued I shall ria employ Work any person at 8fry mariner 90 re t0 ARCHITECT OR ENGINEER TEL NO .4azyl
became subject t0 itle WOfka9 CallpefL98f10r1 Lava rL
Date STATISnCAL CLASSIFICATION
Applicant ADDRESS CLASS NO 1�0 Z DNELL UNITS
NOTICE TO APPLICANT If after making this Certificate of 4 r REWIRED TOTAL E 72
Exemption you
of tbl�LaboroCC•odde you must fto the orthwith \rkera �M D C0JSTAAC•`%61U � "5' f) sET BACK vARD Ifwv I'Ro • 1
_ 4 PL CHECK 168 .72
tangly,with such pnwtsiore or this permit shell be deemed revoked 1,gg)
LIC "O P L
LICENSED CONTRACTORS DECLARATION CITY IaH N; CLASS SP1DE .00
I hereby affirm that I am licensed underprovlslPre of Chapter 9 SEWER MAP
(commerlci g with Section 7000)of Division 3 of the Business and StZE NO OF STORIES NO OF FAMILIES
Professions Code and my license Is In full face and effect
7� NEW BK Po 0000-0001 77277954
License Number b 6);6 106 tic Class �_ N DF W1 fK I ADD ❑ 1AL14T10N
ALTER ❑ 1 ate• �O 1595 1 PM 5:21c8i
Contractor RUNG �{� Date 01 —; i �q� $ �i.J
cc
❑ I am exempt under Sec REPAIR ❑
BBPC for the reason DEMOL ❑ Lp.IA A1C W
Date OF EXISTING BLDG - URM ❑ d
Slpnatum APRICANi(PA4.T1 TEL NO LOW Form♦ 1 1 CD
❑ as axner of the property a memployeesalpla
y with we as 27
their Sale compensation Is will do the work and the structure ADDflESS _ F
net Intended or offered for sale (Season 7044 Business and FINAL DATE
Professions Goes) _Z 1594 20
11R THE APRLIC OR FlfR,PE BUILOnIe OCPMA_ HAlCLE A RALJi MR MRENN.
❑ 89 OWref Of the Property am eXC11191Ve1y CPrltra0tlfg With ml A,TriMEXE IREI)i WNp A HAZ<f>OW91MTERAL EGUAL T]OR PR£ATER TWN ME
M1nE119 3PECEEO W THE HAZMCDLl4 MATERVL9 NFORMATpN GIlIOE2 FINAL BY
licensed contractors to construct the Protect (season 7044 vEs❑ No❑
Business and ProfessiOns Code) 1
NILE RIE IREOLIRO USE a THE BOI,i BY THE ARI.RINT OR RROm E E 8O.J a
OCCAIMNR fEO11RE A PEPAR FOR CONSTRLCnIX1 R9\IPOFICATKIN Ff10N ME 9ClITH
CONSTRUCTION LENDING AGENCY coAsr NR ouALnv euNAOEMENr nL41RILT Iscrowol sEE I£RAfTTI.e cuECKusr roR
hereby affirm that there Is a construction IRdsrg agency forCl _ -
n the performance of the work for which this penrnit a Issued(Sec I
N 3097 CN C) (HAVE READTIE HAIAfLCIIa MATEf4LRINFORWTpNOUOE MATHE 9CAq.`DPERAYTTYA �•I A>A(/_l�1 �� C•
GECIOJST I U10ER1T W REOUIRE�OWER THE Los NgELES COUNTY COOS
Lender 8 NameTITLE 2 CHAPTER 220 SECT IS 210 100 TI{ig1pH 2 20140 CONCEHN W O IJSNNOIIa
AIATEBAle PEPpHiINp ANp FOR OHDlENO A PEN.Ei FRCM THE sCAWO
Lenders Address
I certify that I have read this applscaten and state under penalty
5z� of perjury that the above Information Is correct I agree io conspty PC FEE PERMIT FEE /
ry with all county ordinances and State laws relators a busitllnp (O.
S constructor hereby aut ze repmsentatnres PI this County ISSUANCE FEE �(O
toe mentioned Property fa inspectl0n s a/
INVESTIGATION FEE TOTAL FEE
Il � a. 7 ,91
SEE REVERSE FOR EXPLANATORY LANGUAGE