HomeMy Public PortalAbout5303 BALDWIN AVE_Building__ (2) a. -
3 •;
WORKERS' COMPENSATION DECLARATION
herebor la m that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT
-sure, ora certificate of Workers' Compensation Insurance,
" "�cerLied copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
• Policy No. " Company-
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ompany"-
❑ Certified copy is hereby fLSILDING BU
T
urnished. FOR APPLICANT TO FILL IN BUDRESS�903 6(. AI.
❑ Certified copy is filed with the county building inspec- BUILDING
f
tion department. . a _ ���
CITY' %�A( �' C ! ZIP �/� �y LOCALITY
Date Applicant rr M,Irv-
NO. OF BLDGS. �. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT J� SC NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL. USE ZONE MAP
OWNER J �'� �!� I� NO. NO.
I certify that in the performance of the work for which this
permit is issued, shall not employ any person in any manner ADDRESS r'- •C �`�`J SPECIAL d
CONDITIONS O
so as to become subject to the Workers'Compensation Laws. 0
CITY ' ZIP � �
Date Applicant ARCHITECT OR TEL. DISTRICT G UP TYPE FIRE ROCESSEDBY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONS . NE t-
Exemption, you should become .subject to the Workers' hf� U
Compensation provisions of the Labor Code, you must forth- ADDRESS J P 0.
with comply with_such provisions or this permit shall be TEL. L _ STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION LIC., CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �C 41/",V NO' ���!'��
(commencing with Section 7000)of Division 3 of the Business 1 LIC SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
W_1//
�� // SQ. FT. NO. OF NO. OF ,/ CHECK
License Number /"_1/j 2 //YLic. Class SIZE ��/ STORIES FAMILIES y ONE
/ `_ VALLI TION
Contractor 4:/% (-� 6 Date DESCRIPTION OF WORK rrQl t�� NEW ❑ $
� , 0
0
❑JI am exempt under Sec. no �— ADD (((��J ►
ALTER ❑
B.&P.C. for this reason / REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL.
g OWNER-BUILDER DECLARATION (PRINT) '/� /f c� �2i NO./V'?Vr-Z' FINAL p i
I hereby affirm that I am exempt from the Contractor's License DATE
4 �1
Law for the following reason (Section 7031.5, Business and ADDRESS t'I i FINAL 1
Professions Code): PRESENT By / M1
BUILDING C °g
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and 3 407 209.225
the structure is not intended or offered for sale(Section LOCALITY ITEMS
7044, Business and Professions Code.) MOVING TEL. '
❑ I, as owner,of the property, am exclusively contracting CONTRACTOR NO.
209 -25
with licensed contractors to construct the'pADDRESS roject (Sec- TOTAL
�f ,r
tion 7044,. Business and Professions Code. `• CHECK REQUIRED TOTAL SETBACK FROM EXIST. C•}iEti� it l °6_t
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT CHANGE G °CIO
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE �ry�• y �yry i /
P.L. 0000-000 4 9f 8'/1r�'
Lender's Name '
P.G Fee$ Permit Fee ! LDMA Ref. # 5951 1 AMi i:5
Lender's Address it
o I certify that I have read this application and state that the Issuance Fee 815LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee
6 ordinances and State laws relating to building construction, Total Fee ° .5 LDMA Perm. #
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a and hereby authorize representatives of this County to enter
upon the above-me ned`pr y Qr ction purposes. a
SEE REVERSE FOR EXPLANATORY LANGUAGE
l� n re of Xppficctnt o Agent Date -