HomeMy Public PortalAbout5262 SERENO DR_Building__ -WORKERS COMPENSATION DECLARATION
sure or
certificate
that haver certificate of consent to ce, APPLICATION FOR BUILDING PERMIT
insure, or a cemficata of Worker Compensation Insurance, � � �
or a certified copy thereof (Sec 3800 Lob C ) _ COUNTY OF LOS ANGELES — BUILDING AND SAFETY
TPolicy No Company
❑
Certified copy is hereby'furnished FOR, APPLICANT TO FILL IN AADDIDREu 5a?/��Z
•❑ -Certified copy is filed with the county building inspec- - BUILDING S Zrli7i 1 i1 - "
non department '°�RESS
Date Applicant arri—OPT11C CrH ZIP LOCALITY '
No OF BLDG NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST
COMPENSATION INSURANCE - � LOT NO O - ASSESSOR �
' (Thu section need not be completed if the permit is for one TRACT BLOCK MAP BOOK . pgCE pgjLCEI
hundred dollars ($100) or less ) A... ,, 1 TEL
rlvAq/r • 1 — USE ZONE A
I certify that in the performance of the work for which this OWNS �� (s 7
permit a issued, I shall not employ an person m any manner ADDRESS -ell -� �I'� �a
so as to aces subject to the War cep nsot ,. A p CONDITIONS O
CITY 6�C..�.f/ ZIP
Dara Applicant Q ARCHITECT `�/ 1 r �p 0
NOT[ TO PP Applicant
If, a thi Certificate of ENGINEER tT tv L/1 �T/ 'll DISTRIR GROUP TYPE IRE PROCESSED BY Q
Exemption you should become subject to the,Workers' ��,�.���-ss�� `�rJ] �p TYPE ZONE
Compensation provisions of,the Labor Code, you must forth- __ ADDRESS36 WY"/ 0`T'IT� ,�_ `d`r
with Comply with such provisions or this permit shall be TEL STATISTICAAPT CONDO Z
deemed revoked I CONTRACTOR L CLASSIFICATION N
NO -
LICENSED CONTRACTORS DECLARATION LIC CLASS NO 00 DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 _ ADDRESS NO
(commenting with Section 7000)of Division 3 of the RumLIC SEVER MAP
ness "
and Professions Code,and my license is in full face and effect CITU CLASS PG VALIDATION
SO NO OF �I _ NO OF CHECK
License Number Lic Claes SIZE STORIES C/ FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑ $
' N'F�rJ D , ADD
❑I am exempt under Sec . ALTER
B&P C for this reason -
REPAIR $
❑
Irate USE OF 1•C' ,
EXISTING BLDG DFMOL ❑ r, _
Signature• APPLICANT TEL -
`OWNER-BUILDER DECLARATION (PRINT) NO DATE
I hereby affirm that I am exempt from the Contractor s License _ _
Brio for the following reason (Section 7031 5 Business and ADDRESS FINAL ' HD_P, �::,5•�'
Professions Code) _ r _ BY _ t
E
❑ I as owner of the property, or my employees with BADD ESS
wages as their sole compensation will do the work and
the structure is not Intended or offered for sale(Section LOCALITY
V r•• ' l
ILS/7044, Business and Professions Code ) MOVING TEL
PiI as owner of the Property,am exclusively contracting CONTRACTOR NO IVI, A��..,`4 i Ci.� +
with licensed contractors to construct the project (Sec- f,i :'` C ` T
tion 7044, Business and Professions Code ) ADDRESS I .� r i, � 1725.95
IRED YARD FTWY TOTAL SETBACK FROM -E%I (� -1r
CONSTRUCTION LENDING AGENCY SET BA LINE -
hereby affirm that there is a construction lending agency for FRONT ! —+i 5 j L j 1 IT05
he performance of the work for which this permit is issued P L - + C - TOTAL 1725.95
(Sec 3097, Civ C ) SIDE ry���L/ -�,t� p�
P y�TGM 1725.95
4 Lenders Name o /y �� .'. .
^
PC Fee 6 C Pamn Fee Ref N T"r
Lenders Address , rlrlllv�
,I certify that I have read this application and stale that the Lwome Fee �S�' LDMA P/C N
above information n corect I agree to comply with all County Invnapanon Fee rJ f G CO00-0001 4/29/93
ordinances and State jaws relating to building construction, Total / a ,�j / z}, LDMA Perm N
Q and herebtAn4horize representatives of this County to enter 9452 1 AMIC-00
R84 upon me red pe for impect� r
n zNE NEVENL!FON EXRANATONY LANGUAGE T i
not of Appfriconi or Agent Dale ,
t