HomeMy Public PortalAbout9073 ACASO DR_Building_0 i
WORKERS'COMPENSATION DECLARATION
heYeby'off4rm that I have a certificate of consent to self APPLICATION FOR S U I L D I NG P E R-M I T
sure, ora certificate of Workers'Com on Insurance, or "
FtecoAytJi% Sec 3800, C T' COUNTY OF LOS ANGELEj. , BUILDING AND SAFETY
,cy'N Comport
"FOR APPLICANT TO FILL'IN B ISG n
Certified`copy is•hereby-herebyed Q - ADDRESS !� �1JyG�.U' /�-
Certified• - y is filed with the'countyft; ing insp/ BUILDING 04i
tion department ADDRESS ', LOCALITY
NEAREST
te. Applicant CITY ZIPCROSS
CERTIFICATE'OF EXEMPTION FROM WORKERS' I I / j NO OF BLDGS ASSESSOR t
r - COMPENSATION INSURANCE SIZE OF-LOT NOW.ON LOT - MAP BOOK I PAGE PARCEL
J USE ZONE MAP
his,sectiori need not-be completed if the permit is for one --# �� ' 4P"- 070 Q 17
TRACL LOT.NO.EL NO
'ndred,dollars+($100)or,less )' £ / 1 }
+ CIAL
OWNER 41f WrI f ,e,,Vg NO CONDITIONS 0
certify that in`the performance of the work for which this �-DlTRICT GROUP TYPE FIRE P EDB c (Ojr s tis issued, I shall not employ aers'C son in any manner ' ADDRESS Q AV " CONST.3J ZONE
as to become subject tothe Workers'Compensation Laws � �(�
ate Applicant` ` ' C CITY Gt �/ ZIP f 7 STATISTICAL CLASSIFICATION PT• COND U
ARCHITECT OR.. TEL n ' /
OTICE TO APPLICANT' If,'after making this Certificate of ENGINEERNO l�L r W
cemption, you should become subject,to the Workers' E CLASS NO DWELL UNITS y
ompensation provisions of the Labor Code,•you"must forth- ADDRESS` ` - , SEWER MAP r Z
,ith comply with such provisions or,this permit shall be.-
eemed evoked t . ,, CONTRACTOR �L- TEL / BK4J PG L VALIDATION-
RL��/�. %Jfi i NO 7 /— v
rLICENSED CONTRACTORS DECLARATION, r /� LIC '
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS L e440i L NO VALUATION
:omnen cing with Section 7000)of Division 3 of the Business and LIC
•ofession's Code and my license is in full force and effect CITY J��✓ n /77lr CLASS _ $ ! ��� t '
' SQ FT NO OF' NO OF CHECK
cense Number Lic Class SIZE STORIES FAMILIES ONE
DESCRIPTION,OF WORK- L�Ii/lQ(/ / �� W ❑ r
on;rdctor Date t - -
JI am exempt from the licensing requirements as I am a Q/jVp y J/s! jN,�� .l, T G' ADD ❑
licensed architect or a registered professional engineer ALTER FINAL
acting in my professional capacity (Section 7051, /uFYv I/Y/W006V REPAI ❑ DATE
Business and Professions Code) r USE OF . G /�y6/?`• FINAL ,
- EXISTING BLDG �' DEMOL ❑ By s./
c or Reg No Date APPLICANT TEL _
OWNER-BUILDER DECLARATION' (PRINT) - NO -
hereby affirm that 1 am exempt from the Contractor's License
3w for the following?reason (Section 7031 5, Business and ADDRESS
,ofessions Code)
PRESENT
�. BUILDING _. 9 2 5 6i 0 A
I, as owner of the property, or my,employees with ADDRESS
wages as their sole compensation,will do the workeand a, # o o e • a
' the structure is not intended or offered for sale'(Section LOCALITY
2
7044, Business and Professions Code MOVING TEL QQ �
CONTRACTOR NO
]r 1,•as-owner of the property, am exclusively contracting '77 FJ
with•licensed contractors to construct the project (Sec-
tion-7044, Business and Professions Code) - -
x rREQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SET BACK YARD' HWY PROP LINE WIDTH v
hereby affirm that there`is a construction lending,agency for FRONT
ie performance of the work for which this permit is issued P L / Y
iec 3097 ICiv C') • SIDE
PL
moer's Nome
� �.....
•.
ender s Address P'C fee$ Permit Fee --
�ji- _
certify that I have read this application and state that the Issuance Fee . -
)ove information is correct I agree to comply with all County Investigation Fee d
dinances and State laws relating to building construction, Total Fee
id hereby authorize representatives of this County to enter _
s
&nh 4cabeeHiro ed p�Qperty,.for inspection purposes , ' ' y
�(�1 e
// SEE REVERSE FOR EXPLANATORY LANGUAGE l
Signature of Applicant or Agent Dae - `• r
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