HomeMy Public PortalAbout5243 SERENO DR_Miscellaneous__ WORKERS COMPENSATION DECLARATION CE 875 MISCELLANEOUS APPLICATION {�
• CE 876 (2 601 u
I hereby affirm mat 1 Neve a certificate of consent m salt
msu}e, or a certificate of Workers'Compensation Insurance or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
a certified copy thereof(Sec 3800 Lib C)
Policy No Company FOR APPLICANT TO FILL IN BUILDING r
A
DOMESS
❑ Certified copy rs hereby furnished BUILDING <7 L--.LIT-
❑ ADDaseS L
Certified copy Is filed with the county budding inspection NQA Resr
department LOCALITv eaosa ar +
Date Applicant NEAR Q8T pit ICT GROUP TY PH •ROCH88H BY
CPO* fT 'O CONE R
CERTIFKATE E EXEMPTION FROM WORKERS LEGAL IP
DGBC RiPTION LOT NO BLOCK Q/�wt STATE MAJOR SECOND LOCAL }
COMPENSATION INSURANCE MA• aww++
No OF GLOSS ND (clwc L.1
(This section need not be completed d the work involved TRACT Nox ON LOT USE ZONEaP CCIAL CONDITIONS
by the permit Is for one hundred dollars ($100) or less) USE of / U
r
I candm y that the performance of the work for which this SIZE OF LOT Ex PTING BLDG cc
permits issued I shall not employ any personin any manner OWNER a!z• +
so as to become subject to the Workers Compensation Laws MAIL OCCUPANCY GROUP (,
ADOR assW
Date Applicant
d
In
NOTICE TO APPLICANT If after making this Certificate of CITY ^ TEL
OCCUPANT LOAD Z
Exemption, you should become subject to the Worken
Compensation provisions of the Labor Code you must forth APPLICA ION FOR I EXIT HARDWARE
with comply with such provisions or this permit shall be TRAILS R Use❑ GEOLOGY INs•HeriON I NO Spec KnOW� ❑
deemed revoked ❑ El
INSPECTION Panic Devices
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ ILIST ITEMS BCLDwi I
9 (commencing with Section 7000) of Division 3 of the Busi NO OF EXITS
nese and Professions Code and my license is in full force and
effect Adeej& ojzOI PARRCINa
SEs RHD D PROVIDED
License Number m PA
LClass ���� LIMITED TIME USE
Contractor Date DATE DATE
❑ 1 am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer SIZE oR ST oP Ir loll TO" s
acting in my professional capacity (Section 7051 Bus- EXISTING BLDG aro Rlca -� 1 4r11gt LfJ
IN
mess and Professions Code) PRESENT USE OF BUILDING FINAL APPROVAL Y // _J�
LIC or Reg No Date CO O Q"-
HOME OWNER BUILDER DECLARATION NoOF EXISTING BUILDINGS
ON LOT ANo U IS2 DV
I hereby affirm that 1 am exempt from the COntidLtOra
License Law for the following rLason (Section 7031 5 Bust
nese and Professions Code) NO PARKING
B
❑ I, as owner of the property will do the work and the PAC ES PROVIDED
structure is not intended or offered for sale (Section
7044 Business and Professions Code) PROPOSED USE OF BUILDING -_90 4 7.8 A
CONSTRUCTION LLNDING AGLNCY
I hereby affirm that there Is a construction lending agency # • • • • 30
for the performance of the work for which this permit is
Issued(Sec 3097 Civ C) 2 • • 80,50
Lenders Name t
PROPOSED MAX OCC • •i• 8 0 5 0 5
Lender s Address PERMIT FEE lO
I certify that I have read this gree to con and state that my
0413-84
above information s correct I agree to comply with all County ISSUANCE wee
ordinances and State laws relating to budding construction TOTAL FEE
and hereby nuZnj�4td
rese at,
es of this County to enter
Pon,090 b roperty for inspection purposes SEE REVERSE I OR EXPLANATORY LANGUAGE
r
Slgnatu At Perml tae Da e