HomeMy Public PortalAbout4826 BALDWIN AVE_Building__ (2) J WORKERS' COMPENSATION DECLARATION
insure,hereby
affirm that I ha certif certificate of Worke s' Compensatiove a certificate of n
ent to selfInsurance, APPLICATION
FOR
BUILDING
PERMIT
or a certified.copy thereof.(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING ( -
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS fJ
0 Certified copy is filed with the county building inspec- BUILDING .; �l �GD�/� 4��
tion department. ADDRESS
Date Applicant' CITY i� l�/"� ��Tr ZIP V LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR �J [�r�
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE w, PARCEL �3Z-
hundred dollars ($100) or less.) y�A TEL.
OWNER ///7 f= /Y/YN «d'Al// NO. 11y4{-,'Z/ USE ZONE AP
I certify that in the.performance.of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS /O �j��//�/'✓/�j/ j/ SPECIALCL
so as to become subject to the Workers'Compensation Laws. CONDITIONS O
CITY ZIP 790 U
Date Applicant ARCHITECT ORTEL �
NOTICE TO APPLICANT: If; after making this Certificate of ENGINEER NO DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZONE ~-
Exemption, you should become subject to the Workers' U
Compensation provisions of the Labor Code, you must forth- ADDRESS 0� - 3 d
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. to
deemed revoked. CONTRACTOR �P.r-,,>9Gt� NO. z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)'of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE I STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑ $
❑I am exempt under Sec. �FOLA�g S WCa,✓ wrled4 ADD ❑ P`ALTER
B.&P.C. for this reason Yt//�t/!�D✓✓S. i✓/Tff ALaAl SL/P.f,� $
REPAIR ❑
Date: USE OF
EXISTING BLDG. ' DEMOL ❑
Signature APPLICANT A `� TEL. FINAL
(PRINT)./�/¢� y/t/iy ��Bif�� NO. 7 7 7 /�
' OWNER-BUILDER DECLARATION DATE JZ - j�^�•
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code)'El : PRESENT By 41,1"17
BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole comPensation,will do the work and ,
the structure is not intended or offered for.sale(Section LOCALITY T _ r C,,_:
7044, Business and Professions Code.) MOVING TEL. i ._T _
LILI I, as owner of the property, am.exclusively contracting CONTRACTOR NO. 1!!
-
with licensed contractors to construct the project (Sec- r•I ` "w
tion 7044, Business.and Professions Code.) ADDRESS i t.Y'g:riL •�_ +I._,Z;
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST, :;3�H ?,£�
SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance.of the work for which this permit is issued P.L. kk
-
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name d'PYtC(%3 -h,,-;; : ,;=•;
��� LDMA Ref. #
�
ee
- P.C. Fee$ Permit F •- _s -
Lender's Address €iti„ =`rtst,l zfyl•
1 certify that I have read this application and state that the Issuance Fee 0941-Ar
LDMA P/C# , E-q k ”?
O above information is correct. I agree to comply with-all County Investigation Fee
6 ordinances and State laws relating to building construction, Total Fee z�l 3 LDMA Perm. #
a and hereby authorize representatives of this County to enter
u o t e above-m tinned pr for A ection purposes.
P P Y P P P
/mac SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ure of Applicant or Agent Date
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