HomeMy Public PortalAbout5242 SERENO DR_Building__ )
WCIPERS' COMPENSAJION DECLARATION
APPLICATION FOR BUILDING PERMIT
I hareby, affirm that r have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance,
or a certified copy thereof (Sec 3BDO,'Lab C ) COUNTY OF LOS ANGELES ' - BUILDING AND SAFETY
Policy No Company BULLDING '
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL INApDR
El Certified copy Is filed with the county building Inspec- RE55 ^� /Cf� N
tion department pp
Date . - Applicant CITY If- - ZIP 1 U LOCALITY
NO OF BLDG5d A,L NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT /r L CROSS ST - -
COMPENSATION INSURANCE �7
c his section need not be completed if the , G0 BLOCK '� LOT NO t/' ' '- ASS BOOK ' - PAGE PARCEL
(T p permit ICI fa one TRACT L Ch`AP
'hundred dollars ($ 00) or leas ) - '{� T �/ TEL USE ZONE MAP /
4 `f� OWNER J R ` NO�/lI'10/�L - _
I comfy that m the performance of the work fa which stirs �t
mit ICI trued, I shall not employ any perso In arty manner ADDRESS l�7 W � �(/� /Q-P ISPECIAL
CONDITIONS 04
�as to becom subject to the Word' I n La .t O
CITY R e o ,,A ZIP ���7 - V
• Date Applicant ARCHITL{T OR ac
NOTI TO CANT If oft ak I Certl mte of ENGINEER U/YI Nal),/--7q' RI GROUP TYPE FIRE PROCESSED By O
Exemption,.you-'should become subject to the Workers CONST1 / ZONE r
Compensation provisions,of the Lobo Code, you must forth- _ ADDRESS
with comply with uxh provisions or this permit shall be STATISTICAL CLASSIFICATION AT CONDO
deemed revoked CONTRACTOR NO Z
LICENSED CONTRACTORS DECLARATION I LIC CLASS NO DWELL UNITS2L
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP '
(commencing with Section 7000)of Division 3 of the Business . uC
and Professions Code,and my license is in full form and effect Cir CLASSW11V PG VALIDATION
50 FT /� ' NO OF NO OF CHECK
License Number LK ClassZE f STORIES�- FAANUES ONE- VALUATION
Contractor Dote DESCRIPTION OF WORK NEW Cj s/
❑I am exempt under Sec t A1TER ❑ _
B 8P C for this reason REPAIR ❑ S
i
Date USE OF EXISTING BLDG DEIAOL ❑
' Si nature APPLICANT TEL t`
g OWNER-BUILDER DECLARATION (PRINT) NO - - FINAL
DATE
I hereby off rm that I am exempt from the Controctor's License ^
Low for the following reason (Section 7031 S, Business and ADDRESS FINAL ,
,Ipr
ofenrons Code) NT By t. Ni , .i
❑ I ora owner of the BUILDING ,
properly, or my employees with ADDRESS ` -
woges m their sole compensation,will do the work and (`�1-
the structure ICI not"tended or offered for sale(Section LOCALITY1r-
/V. Sltf iD
L� 7044, Business and Professions Code ) MOVING TEL i' 1 _
CJ 1,m owner of the properly, am exclusively contracting CONTRACTOR NO }( 't ,•is r fr AL
with licensed contractors to construct the protect (Sec- - ADDRESS - +�)�'�" �•
tion 7044 Business and Professions Code ) 'TPL
CONSTRUCTION LENDING AGENCY ' SET I D YARD HWy u lua FROM
IM
REQU
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued 'P L
(Sec 3097, Civ C ) SIDE O C?
PL
Lender's Name _ y , }I`- Iyy1�
Lender's Address
PC Fee f OL Permit Fee Q/• 0 DMA Ref Y I t SIC(,IhyM-
I certify that I have read this application and state that the - - Issuance F . �r/� LDMA P/C Y
above information is correct I agree to comply with all County - Investigmlon Fee / 3 p7 / a LDM -
ordinances and State jaws relating to budding construction Total Fe/� A Perm
< and hereby authorize representatives of this County to enter
RnY4 upon th -me red w arty for Inspection p 'poses E+
L//
SEE REVERS FOR EXPLANATORY LANGUAGE .Cpm O �S
r at App Icons or Agent Dote JI 6 O