HomeMy Public PortalAbout5266 SERENO DR_Building__ e WORKERS COMPENSATION DECLARATION n
-1 thereby affirm that I have on, tell APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers
certificate of consent
Compensation Insurance, i
or a certified copy thereof (Sec 3800, Lab C ) _ COUNTY OF LOS ANGELES- IBUILDING AND SAFETY
Policy No - Company
BUILDING❑ ,&Certified copy is hereby furnished � - FOR APPLICANT TO FILL IN ADDRESS s:� '
❑ Certified copy a filed with the county building irgp - BUILDING -
hon department ADORF55 /J
Data Applicant O NO ZIP I PI 8o� LOCALITY G'G
OF BLDG NEAREST
CROSS T
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOw ON LOT
COMPENSATION INSURANCE" -` C r ASSESSOR
o
(This section need not be completed if the permit is for one TRA 5b� _ BLOCX LOT,NO MAP BOOT( g PAGE IQ PARCEL
hundred dollars ($100) or less ) . �� _ - NL+" "6 115E,Z0� MAP < 07 _
OWNER 1 /
I certify that in the performance of the work for which his `gyp, D
)'- NO
permit is issued, I shall not employ any pe n m any manner` ADDRESS - A /L, CONDITIONS a'
SPECIAL
so as to ons subject to the War o pen h a Q M1 - - _ O
JCITY - ZIP
Date t Applicant ARCHITECT O K
NOTI T APPLICANT If, ofte nq is Certificate of ENGINEER lr�ry�/- I 7'3 DISTRICT GROUP O�DNST - ZONE PROCESSED BY Q
Exemption, you should become subject to the Waken ,, ..`` _ ` (I �� V
Compensation provisions of the Labor Code you must forth ADDRESS;3&") l-I`� d�PA-
-with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION _ APT CONDO vl
deemed revoked i. CONTRACTOR NO z
UCENSED CONTRACTORS DECLARATION L UC CLASS NO��DW'ELL UNITS
I hereby affirm that I am licensed under provisions of Chapter9 ADDRESS NO SEWER MAP
(commencing with Section 70DD)of Division 3 of the Business UC
and Professions Code,and my license is in full force and effect _ Cllr CLASS BK/h PG _ ' VALIDATION
• SO FL IC50 NO OF �7 _ NO OF CHECK -
License Number Lic Class SIZE lilJ..[l STORIES (/ FAMILIES VALUATION
DESCRIPTION OF WORK NEW E
Contractor Done ✓`f�
Elam exempt under Sec ` 'O T�•" r�T ` "❑
') ALTER- ❑
B 8P C for this reason LISE OF
REPAIR ❑ $
Date IXISTING BLDG DEMOL ❑
_. Signature APPLICANT
No FINAL I_I'iLi''. i- ^•�,"
OWNER-BUILDER DECLARATION DATELp-" _ _ •III_
I hereby affvm that I am exempt from the Contractor's License - - - - H v ]t
Law for the following reason (Section 7031 5, Business and ',WRESS FINAL
Professions Code) ' I I PRESENT - - - - - I By
❑ I, as owner of the property, or my employees with BUILDING
a J
wages as their sole compensation,will do the work and \ q(��_ L 1 t
the structure a net intended or offered)forsole(Section ry LOCALITY
ING ` s �- 1 ' �1;,i 1 =-
7044, Business and Professions Code JJJ�" MOVING TEL -'
I, as owner of the _ ? - l _
property,am exclusively contracting CONTRACTOR NO t 3 /_ (' .; I �•1 �r\�W 1732.711
with licensed controcton to construct the project (Sec- ADDRESS -�/ �,,, . +.• 1'ITEliS
tion 7044, Business and Professions Code )
YARD HWY TOTAL 17'2.7[1
'CONSTRUCTION LENDING AGENCY SET I u ac FROM I 1 t
I hereby affvm that there is a construction lending agency for FRONT _ t i •iP) r, 1 I
the performance of the work for which this permit is issued P L t CHECK 1732.70
(Sec 3097, Civ C ) SIDE `uAsyr _
- PL _ _ -_ _ _ bFTrmVG • 1
Lender's Name
g LDMA Ref ♦ J `
Lender's Address P C Fee 3 Permit Fee .0 /� 4/29/9.
I certify that I have rood this application and state that the Issuance Fee J LDMA P/C It ► C34 1 Ah 1��U1
above information is correct I agree to comply with all County Inve.tigotion Fee - _ // a -�D
ordinances and State laws relating to building construction, Total Fee / • LDAkA Perm
and hereby authorize representatives of this County to enter - _ - _ _
upon th ire menti ed pe ry for inspecto�.p
^ �J SEE_REVERSE FOR EXPLANATORY LANGUAGE _
L,94.dfureilof Applicant or Agent Dote '