HomeMy Public PortalAbout5256 SERENO DR_Building__ WORKERS COMPENSATION DECLARATION
I s6reaffirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure,, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof(Sec 3800, Lob C ), _ COUNTY OF LOS ANGELES - BUILDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnishedr FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- REu 7 ZLAI
tion department - _
Date Applicant CITY- �jt'yI T'Ki ZIP 80 LOULITV NEAREST
-
NO OF BLUUb
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT NOW ON LOT - CROSS
CROSS ST
COMPENSATION INSURANCEo� p�Srgp
(This section need notibe completed if the permit is for one TRACT - BLOCK LOT NO Q rtAP BOOT( PAGE lO PARCEL
hundred dollars 1$,00)or leu ) TEL /j.p Z / r
OWNER NO —/DUSEONE 4,:
1 certify that in the performance of the work for which this
J permit is issued, I shall not employ an n in on mon r ADDRESS - e-.;2 COFIDmO IS Q.
w os to o subject to the W Co pe i a O
` CITY ZIP eo 7 U
Dote Appliccn ARCHITECT "y� DI GROUP TYPE I PROCESSED BY O
NOT T APPLICANT If a ng a Certiflmte of ENGINEER 3Y/ CON57 ZONE r
Exemption, you should become subject to the Workers' �
, O�y 3 ,Y,
Compensation provisions of the Labor Code, you,must forth- \ ADDRESS 1/ ✓✓ SS
�^
with comply with such provisions,or this permit shall be TEL STATISTICAL CLASSIFICATIONCO
APT NDO 'Z Z
deemed revoked 11CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION �- UC CLASS No 4--1DWELL UNITS_
1 hereby affirm that lam licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP
,
(commencing with Section 7000)of Division 3 of the Business UC
and Profession Code,and my license is in full force and effect CITY CLASS BK PG VALIDATION '
SO NO OF �fj FLO OF CHECK ' , i
License Number Uc Class SIZE �� /V NO
FAhVUES ONE n
VALUATION li'_l T.r
Contractor . Date DESCRIPTION OF WORK NEW $ �{o L/ ! 97
El am exempt under Sec
ADD , 1 ITF9_ ,
_ ALTER_ ❑ - '
B 8P C for this reason ` -
pv REPAIR ❑ $ I IfIT�.L ii 4�lf
M1° USE OF EXISTING BLDG DEMOI ❑ t rG�fL 1al! ,C
Signature APPLICANT - TEL
g OWNER-BUILDER DECLARATION (PRINT) - NO - FINAL �tiahl,�r �il'I
DATEI hereby offrrm that I am exempt from the ControOo/e License _ - -
Law for the following reason (Section-7031 5 Business and '� FINAL
. Professions Code) PRESENT . By �� �H_1 :-
property, w my employees with c� ADDRESS �� ' _ , c
DING
❑ 1, as owner of the _ �+'2F't�/ _ i.� l .
wages as their sole compensation, rwilled do the work and
the structure ss not intended or offered for sale(Section LOCALITYMOVING,
n� 1 ITM
7044, Business and Profeuioni Code ) CONTRACTOR
O TRA TEL (J a
G 1, as owner of the property,am exclusively contracting C�7��� /_%IV`(/' ((`T•)S' T�. -NO
176J•?�
with licensed contractors to construct the project (Sec ADDRESS - . , ((/ ,yTf
hon 7044 Business and Professions Code ) -"/- _ ,( �(-_ - 1765.455
RtOUIRED
i
CONSTRUCTION LENDING AGENCY _ SET YARD HWY OTAL LONEFRQN WIDTH-I /,' ,` CK*K _ Al
I hereby affirm that there is a construction lending agency for FRONT T9aT� _
the performance of the work for which this permit is issued P L
(Sec 3097 Civ C) SIDE ,
PL poli 4/29/93
Lenders Name ��.�f r�1•�'! i
_
PC Fees 6 Perms Fes Zoip• �O 1DMA Ref N 9??9 1 AI 14:5h
Lender s Address t
I certify that I have read this application and state that the - Issuance Fee �.�•loS LDMA P/C N
above information is correct I agree to comply with all County Inveitrponon Fee / f
crdmoncez and State jaws relating to building construction, Total Fe! ��o-i LDMA Perm N
`
and h�thoras representatives of this County I enter = _. -
bYq upon e- ntio pr Deny for rrupecti� sir
7 1— SEE REVERSE FOR EXPLANATORY LANGLLAGN
ere o plimnt m Agent Date