HomeMy Public PortalAbout5252 SERENO DR_Building__ WORKERS COMPENSATION DECLARATION -
yreby affirm that I have certificate of consent to self
insure,
,APPLICATION FOR, BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a cemF;ed copy thereof (Sec 3800 Lab C ) :� COUNTY OF LOS ANGELES ,. -BUILDING AND SAFETY
Policy No Company '
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADD1DRESS
❑ Cerhfted copy is filed with the county building inspec- BIIILIXNG y S G40A!5AV 1iN —
non department
Date Applicant CITU f NO OF 2BI LOCALITY
• _
CERTIFICATE OF N FROM WORKERS' SIZE OF IAT - NOW ON LOT NEAREST
•-- CROSS ST
COMPENSATIONSATION INSURANCE ,{j
(This section need not be completed rf'the permit is for ons _ TRACT BLOCK LOT NO _ O MAP BOOK PAGE A I PARCEL 1 /
hundred dollars ($100) or less ) TEL USE ZONE , i
OWNER - NO 7 _
I certify that in the performance of the work for which this //
permit is issued I shall not employ any person in any manner ADDRE Lr/ SPECIAL d
so as to oma subject to the Wo on [ � CONDITIONS O
EC/ CITY C. ��-+ ZIP �� 1
Dale` A licant ARCHITECT /k7'/' Dc
NOTI TO APPLICANT if m g t s Ce ficate of ENGINEER //fG y -DISTRICT GROUP QST FIIE PROCESSED BY Q
Exemption, you should become subject to the Workers l
Compensation provisions of the Labor Code ���
pe p you must forth- ADDRE55
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFLCA.TION APT I CONDO Z
deemed revoked r0i CONTRACTOR NO CESS NO DWELL UNfTS�
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N
(commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP
and Professions Code and my license is in full force and effect CITY CLASS BK PG VALIDATION
SO NO OF NO OF CHECK
` License Number Lic ClassSIZE 7 STORIES FAMILIES ONE
VALUATION
Contractor Dote DESCRIPTION Of WORK NEW f/� ,--
�j ADD ❑
❑I am exempt under Sec` `� Flo
ALTER ❑ _ - ► n. .i
B 8P C for this reason REPAIR ❑ $
Date USE OF
EXISTING BLDG DEMOL ❑ 1 I T EMS
Signature APPLICANT TEL _ FINAL -
OWNER-BUILDER DECLARATION (PRINT) NO DATE .Q_Q 11tH j�41_,y',-
1 hereby affirm that I am exempt from the Contractor's License __ _ V tL - C — 7
Law for the following reason (Section 7031 5, Business and ADDRESS FINAL1.4�.-�
Profession Code)
J,� PRESENT BY
, BUILDING
❑ I, as owner of the property or my employees with \ ADDRESS
wages as their sole compensation,will do the work and N
the structure is not intended or offered for sale(Section -L LOCALITY , (`iJ ` , l' TC(ll ,,_illi- c �fl
-� 7041, Business and Professions Code ) MOVING TEL I i,�'^
I,as owner of the property,y, am exclusively contracting
CONTRACTOR NO
with licensed contractow to construct the project (Sec-
ADDRESS - - - ACCT.0,
-
lion 7044, Business and Professions Code ) C L 1693.95
t-C
LIMED TOTAL SETBACK FROMEXIST � i `
CONSTRUCTION LENDING AGENCY BA Y'� uN r \ ` v
I hereby affirm that there is a construction larding agency for FRONT
the performance of the work for which this permit is issued P L �f k' 1 ITEMS
(Sec 3097 civ C ) SIDE ,
TOTAL 1698.95
Lender's Name _ CHAs
LDMA Ref I ��S (t (�s d G�CK 1693.95
Lender aAddress
^ P C Fa f �- Permli F . y-C .00
2 - - _ , t `F1Tel1'S_- _ - W
c I certify that I have read this applicohon and stole that the Issuance Fee (7s7 LDMA P/C
above information is correct I agree to comply with all County Invntigotion ee /Q ,/ p
ordinances and State laws relating to building construction Toiol Fee N 7 3 • % 6 LDMA Perms OOOD-0001 1/29/93
and hereby horize representatives of this County to enter '
upon th ov -men ed o�p�gJ�t�y for inspection urpos a 9448- 1 AH 9:58
N' SU tEVFlfs FOR EXPLANATORY LAN6UAGN
of App kant or Agent Dote - -