HomeMy Public PortalAbout5250 SERENO DR_Building__ WORKERS' COMPENSATION DECLARATION
Thereby di that I have r cs Comte of consent to ,elf APPLICATION FOR BUILDING PERMIT
insure, or a cefidlcote of Worker Compensation Insurance, -
or a certified copy thereof (Sec 38Ib, Lob C ) _ _ COUNTY OF LOS ANGELES BUILDING AND SAFETY "
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS jB
E3
ElA
Certified copy Is filed with the county building Inspec- ADDRESS
1 hon department ADDRESS
CITY C- ZIP LOCALITY
lbte `Apptim �'fnt __ .NO OF BLDGS � NEAREST '
CERTIFICATE OF'EXEMPTION FROM WORKERS SIZE OFLO7 NOW ON LOT pjp�5T , AOF
COMPENSATION INSURANCE _
(This section need not be completed'If the permit ii for one TRACT��� > BLOCK LOT NO �� MAP SBSORK �,� PAGE J PAR, 7
hundred dollar ($100)or less ) OWNER —f _ / �' TEL 2 USE ZONE MAP
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I Irma that d the performance y f the sok for which thineer `4 t A.&47' 1;,v 1.r i, 4 �ttIONS
rmlt Ia issued, I shall not employ an n In an manner ADDRESS SPKJAL a
/ so as to become subject to the
0CITY O
Date-E���Apphcant ARCHITECtt OR�n..M
TEL
NOTIC O A L NT If, a ng Is Cenficate of ENGINEER /L DISTRICTGROUP CST ZRE*APr
CESSED BY Q
Exemption, you should become sublact to the Workers
Compensation provisions of the Labor Code, you must forth- ADDRESS Y
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION -/ CONDO
deemed revoked \V CONTRACTOR r`h NOq2A 2
LICENSED CONTRACTORS DECLARATION \`T, LIC CLASS NOUNIT
I hereby offum that I am licensed under provisions of Chapter 9 'ADDRESS NO SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC
and Professions Code,and my license Is In full force and effect CITY CLASS BK PG VALIDATION
SO FT NO OF NO OF CHECK
License Number Lic Clan SIZE STORIES FAMILIES ONE "
vALunnoN
Connector Date DESCRIPTION OF WORK -N� ❑ $/5016010
1 `
Elam exempt under Sec - _ ► _ -
B 8P C for ALTER 13this reason REPAIR ❑ $
5E
Date OF"EXISTING BLDG 1' DEMOL ❑ ' Arc, }e
Signature APPLICANT CN
OWNER (PRINT)
NO -
FINAL
h �3N s-BUILDER DECLARATIONp
I hereby affirm that I am exempt from the Contractor s Llcen» \t,
Law for the following reason (Section 7031 5, Business and tl ADDS FINAL '
Professions Code) .. , _ PRESENT - By TUAL
❑ I as .J BUILDING It V71
owner of the
property, or my employees sand "or ADDRESS"
wagen LOCALITY sas theBole compensation,will do the work and U
44he structure Is not Intended offered for sale(Section
70 , Business and Professions Code) MOVING TEL
VVV ' r
1, as owner of the property, am exclusively controving CONTRACTOR NO
with licensed contractors to construct the project (Sec- - - - -
- h 44 on 70Business and Professions Code ) ADDRESS a y)I}QI'IJ—I)Ij
IREDL CK FROM I
CONSTRUCTION LENDING AGENCY' SET BA YARD HWY I y�fY1 i�.� 1, Y4 i 1 �II Lti 1
I hereby offum that there Is a construction lending agency for. FRONT
the performance of the work for which this permit Is'lnued P L .O G
(Sec 3097, civ C> PIKE
Lenders Name
` eI
^ - _ P C Fee S "/O / Permit Fee J TDMA Rf T
Lender's Acidness-
'I
ddress"I certify that I have read this application and state that thelaeonm F 6 LDMA P/C•
above Information is correct I agree to comply with all County •_ Invest,gohon Fee / R �y a ,
ord,nonces and State laws relating to building construction Total F 4 O� LDMA Perm It
sIS ae representatives of this eCo to enter - P
rt .il
'
uw for nspct
SU RlVERM FOR EXPLANATORY LANGUAGE W
gra ire of Applicant or Agent Dote G