HomeMy Public PortalAbout5258 SERENO DR_Building__ #ORKERS COMPENSATION DECLARATION ^
hereby affirm that I have certificate of consent to self APPLICATION FOR ,BUILDING PERMIT ,LII.III,
insure, or a cenificate,of Workers Compensation
tion Insurance, `
or a cgrtified copy thereof (Sec 3800, lab C ) COUNTY OF LOS ANGELES 'BUILDING AND SAFETY
Policy No Company
❑ Certified copy ia'hereby furnished rFOR APPLICANT TO FILL IN BUILDIN foZS�
-E] Certified copy Is filed with the county building irtspec- ADIo�RESS SZ"J r ,
hon department '
Date Applicant OT " ZIP LOCALITY t '
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NO OF BLDGS NOw ON LOT t
CROSSSTi
COMPENSATION INSURANCE /n�`\Q e (J Q
(This section need not be completed if the-permit is for one TRACT J0� BLOCK LOT NO MAP B K PAGE O PARCEL
hundred dollars ( 100)or less ) L
A,kn
OWt�R - NO L15E ZONE AAA.P
I certify that in the performance of the work far which this 1
permit is issued, I shall not employ any person in any mono r - ADDRE p" C µI ONS , Q.
sa as to oma ubject to the Work do a O
ITV zip B-O'/ V
Dote Applicant ARCHITECTceO�M
NOT TO PPLICANT If, aft g is Certificate of ENGINEER - DISTRICT GROUP TYPE FIRE PROCESSED BY Qr
a Exemption, you should become subject to the Workers [� TOA CONST Z E V
Compensation provisions of the Labor Code you must forth- d' ADDRESS LA) r'�7n>•/ 9 ,"9� - � V ify''
with comply with such provisions or this permit shall be \'nV TEL STATISTICAL CLASSIFICATION APi CONDO Z
deemed revoked, - i _ 1 ' CONTRACTOR NO /
LICENSED CONTRACTORS DECLARATION UC CLASS NO DWELL UNITS LL
I here affum that I am licensed under ADDRESS NO
by pion 3 of of Chapter 9 -
,(Commencing with Section 7000)of Division 3 of the Busmen LIC SEWER MAP i , 1
and Professions Code and my license is in full force and effect CIN C m BK PG �. VALIDATION
50 NO OF NO OF CHECK
License Number Lic ClassSIZE Nroo 0 FAAVLIES ONE
DESCRIPTION OF WORK NEW $VALUATION
I�i-(T.
Contractor Dote
� _ -_
ElI am exempt under Sec ADD IJ -
ALTER ❑
8 8P C for this reason REPAIR ❑' f
J L 1 ,
Date EXISTIING BLDG pEMOI ❑ 711 4L
Signature V' APPLICANT _ _ TEL FINAL "- (F-i ' 1G�t�_..'.�i
OWNER BUILDER DECLARATION ♦n (PRINT) NO DATE '
I hereby affirm that I am exempt from the Contractors License - KANrx
Low for the following reason (Section 7031 5, Businesi and ADDRESS FINAL r`
Professions Code) _ L�•(( PRESENT "' _ my
❑ I, as owner of the o `0 BUILDING 1 ]
property, or my employees with ADDRESS r i'll
wages,as their sole compensation,will do the work and { rI ) �p \ `r' _
the structure is not intended or offered for sale(Section LOCALITY , �/rA v\ �T"IJ - .* S • .,r1�]`- '
704 Business and Professions Code) MOVING TEL G IV -
�/ 1,m owner of the y ng CONTRACTOR NO
7 1698.95
property, am construct
the
project
(S /.. r.
with licensed contractors to construct the ro act Sec IIYFF 1 I�GJ' -
tion 704, Business and Professions Code) I ( ��� Y^�„! �.�ii
CONSTRUCTION LENDING AGENCY D YARD HWY T CK FROM IST T TOTAL 1698.95
I hereby affirm that there is a construction larding agency for FRONT E _ ` '/v 1 �_ /t i WICK 16`78.95
the performance of the work for which this permit is issued PL' 'r_ _
(Sec 3047 Civ C ) SIDE - .00
Lender's Name / r I e
' 19/5/ -Z /Co 390 LDAM Ref N OVW-tical 4/L]/9.
P C Fee Permit Fee
2 Lenders Addreu
o I certify that I have read this application and state that the Nuance Fee a( .lol,J LDMA P/C N Pilo9450 1 AM 9:59
above information is correct 1 agree to comply with all County Invesnio
gatn Fee L 9 8 /
ordinances and State jaws relating to building construction, Totol Fes LDMA Perm N
< and hereby authorize representatives of this County to enter
AYE ujwn a ve- ntw d p pony for inspection purposes
SEE REVERR FOR EXPLANATORY LANGUAGE
^ ur o Apptic nt or Agent Da