HomeMy Public PortalAbout5248 SERENO DR_Building__ - WORKERS COMPENSATION DECLARATION _
f hereby affirm that I havecertificate omp of consent to ,elf APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers
r keCompensation Insurance, - ,
ora certified copy thereof (Sec 3B0O, Lob C ) r _ COUNTY OF LOS ANGELES --- - BUILDING AND SAFETY
Policy No Company `
❑ ING
Certified copy is hereby furnished FOR APPLICANT TO FILL IN AADDIDLR
❑• Certified copy n filed with the county budding inspec- _ SS —y G,V'
tion department q
' - CITY ZIP / LOCALITY
DatO Applicant r NO OF BLDGS REST
NEA _
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT - - NOW ON LOT NEAREST
RS Si
COMPENSATION INSURANCE G'` (' f
his section need not be completed if the permit is for ==one TRACE �` 6 BLOC( LOT NO /� R !l PAGE 14'52 PARCEL
hundred dollars ($100)or less ) OWNER %/Z17! USE ZONE MAP
I cenlfy that in the performance of the work for which this ��1 L q SPECIAL d
permit is issued, I shall not employ person in any manner ADDRESS / W I.�L�C AV['1 �o� CONDITIONS
\`l so as to orae subject to the Work rs n ion /1!I 'n ZIP LL' - O
CITY 17 Y�
Date- ApPhcant•' ARCHITECT OR n)i / �� TEL 0C
NOTI TO APPLI NT If, a rnaN s Certificate of ENGINEER CC L DI ICT GROUP TYPE FIRE PROCESSED BY Q
CONST Z
Exemption, you,should became subject to the Workers' 7 w
Compensation-provisions of the Labor Code, you must forth- ADDRESS lop,1 3 V a
with comply with such provisions or this permit shall be TELL,� STATISTICAL CLASSIFICATION / APT CONDO N
deemed revoked CONTRACTOR M NO"/ /7T' off- Z
DC CLASS NO
LICENSED CONTRACTORS DECLARATION /��//7I
__I.ClL_OWELL UNITS
41 hereby offum that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP
(commencing with Section 70DO)of Division 3 of the Business LIC ,
and Professions Code,and my license is in full force and effect CITY CLASS BK PG oZ VALIDATION
SO FT NO OF NO OF CHECK
License Number Lic Class SIZE - STORIES � FAMILIES ONE
Contractor I —Date— `{ DESCRIPTION OF WORK NEW 2,65' _
f`4f S/ J Z 2,65' ►
❑1 am exempt under Sec ADD y
ALTER ❑ - _a
B&P C for this reason
REPAIR ❑ $
Date USE OF
\�
EXISTING BLDG _ DEt`�OL
t ❑ _
Signature 1A APPLICANT _ FINAL_
OWNER-BUILDER DECLARATION UU DATE ItI�P,L
I hereby affirm that I am exempt from the Contractor's License _ _ •-
-Low for the following reason (Section 7031 5, Business and ADDRESS FINAL„
Professions Code) IRRNi _ _ By JA
❑ I, as owner of the property, or my employees with ,UIDRESS
LDINO
wages as their sole compensation will do the work and LOCAUIY - - - Poo
the structure Is not intended or offered for sale(Section 1'V.Y
7044, Business and Professions Code ) MOVING _ TEL
lU/ I, as owner of the propery,'am exclusively contracting CONTRACTOR NO `;�� �L r � , y.vM 1••� I_ l _, aLi 7_
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Cade )
f:RON
YARD HVJV TOTAL SETBACK FROM IST t ("^ 1 IpLyc,
CONSTRUCTION LENDING AGENCY LIN - 1 tM
I hereby affirm that there is a construction lending agency for `` r!! r it i 1 1 -r I the Performance of the work for whlch this permit is issued - - 1r ' '1 VTAL i7i.70
(Sec 3097, Civ C ) /�r�Ir �I� x- _ _ M(LM - 1!W1701
g Lender's Name ` r r
-3^ P C Fee S dPermLDMA Ref t Fee ,O N ! 7 �� ' ' J Vwba •yrs
Lenders Address
a I certify that I have read this application and state that the hsuoncs Fee 6 LDMA P/C N 0600--Ml 4i LZ/9
above information Is correct I agree to comply with all County Invmtigahon Fe_e rO
ordinances and State jaws relating to building construction, Total Fee O✓ / IDM-Perm N 944 1 9:56
AY
< and hereby thorize representatives of this County to enter _ ff L Jct
IYq upon o e-m ho doperty for Inspectlo purpojjes
U SEE REVERSE FOR EXPLANATORY LANGUAGE
no re of Iicant or Agent We