HomeMy Public PortalAbout4914 ARDEN DR_Building__ WORKERS' COMPENSATION"DECLARATION I 715_a70A C•.�ne0a 9-67
� I herebii affirm that I have a Certificate of consent,to self APPLICATION FOR BUILDING ERMIT
insure, or a certificate of Workers' Compensation Insurance, °
or o'certified co'y hereof Sec. 3800, La . C.) I COUNTY OF LOS ANGELES BUILDING J
DEPARTMENT OF COUNTY ENGINEER ADDRESS
Policy'Ce. ' mpany N SAFETY DIVISION
Certified co Is hereby furn ed. BUILDING AND S LOCALITY
PY y JOHN A. LAMBI E, COUNTY ENGINEER �
Certified copy is filed with the county building inspec- COLEMAN W. JENKINS, SUPT OF BUILDING NEAREST '
Tion department. j CROSS ST.
DIST ICT N RO TYPE IRO S BY
FOR APPLICANT TO FILL IN J� CONST.
Date 'U Applicant ( (Print or type only) 6
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGSTATISTICAL CLAS 1FICATION SEWER MAP
COMPENSATION INSURANCE I ADDRESS /- / Arden Drive.. CLASS 10.��DWELL.UNITS / BK/4PC,
(This section need not be completed if the permit is for one ,!y
hundred dollars ($100)or less.) LOT No"Parcel. No., 2' BLOCK USE 7y0 NOP t (/
TRACT D / SPECIAL
I certify that in the performance of the work for which this CONDITIONS
permit is issued, I shall not em to an person in an manner .OF BLDGS7,T
P P Y Y P Y SIZE OF LOT80x.167. 51.+ NOW ON LOT lyOne'
so as to become subject to the Workers'Compensation Laws. USE OF
EXISTING BLDG. BLDG.SETBACK FROM
Date Applicant TEL qq FRONT PROP.LINE OF (STREET).
NOTICE TO APPLICANT: If, after making this Certificate Of OWNER S.Chulz. BrOS . NQ. 28 414Q' TYPE OF EXISTING SETBACK HIGHWAY YARD = TOTAL
Exemption, you should become subject to the Workers I ADDRESS HIGHWAY WIDTH FROM C.L.
Compensation provisions of the Labor Code, you must forth- + (� =
�} AIC41 Opo
with comply with such provisions or this permit shall be i CITY yZ' `��-�r � cQ
deemed revoked. BLDG. ETBACK FROM
j ARCHITECT OR TEL. SIDEPROP.LINEOF (STREET)
LICENSED CONTRACTORS DECLARATION ) ENGINEER NO. _
I hereby affirm that I am licensed under provisions of Chapter 9 TYPE OF EXISTING SETBACK HIGHWAY } YARD — TOTAL
(commencing with Section 7000)of Division 3 of the Business and j ADDRESS HIGHWAY WIDTH FROM C.L.
Professions Code, and my license is in full force and effect. I ��++ TEL. } + _
1 CONTRACTORA ChU.1Z- BrOS'..NO. 28 - {D' C:)
LicenseNumber Lic.Class j ADDRESS - NO 1.2603,
. CORNER CUTOFF YES NO U
' . ❑ ❑ �
CD
Contractor /�"� /J/VMS_"• Date i CITY - CLASS Bm-1 SEE REVERSE SIDE FOR SPEC AL PPROVALS
❑ I am exempt under Sec. DESCRIPTION OF WORK z
B.BP.C. for this reason NEW X,'ADD ALTER REPAIR DEMOLISH
1. DEMOLISH
T
Date: - j SIZE 4:! STORIES {. FAMILIES �.
Signature USE OF
OWNER-BUILDER DECLARATION STRUCTUREReSadence With at.t.a cheC3.
I herebyaffirm that I am exempt from the Contractor's License
P 2. Cir. garage-
Law for the following reason (Section 7031.5, Business and
Professions Code): - AIPPLICANE OF
I, as owner of the property, or my employees with VALUATION $
�/,
wages as their sole compensation,will d0 the work and ✓ (! '' 4 APPROVALS DATE 'I NSPECTO 'S SIGN 0 URE
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). P.C. PMT, FOUNDATION: LOCATION
aFEE $ e�y� FEE $ 3 _ FORMS, MATERIALS ��
I, as owner of the property, am exclusively contracting FRAME: FIRE STOPS,
with licensed contractors to construct the project (Sec- I 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION BRACING, BOLTS
tion 7044, Business and Professions Code). AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY FURNACE: LOCATION,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
CONSTRUCTION LENDING AGENCY BUILDING CONSTRUCTION, I CERTIFY THAT IN DOING THE WORK GAS VENT, DUCTS
AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA-
I hereby affirm that there is a construction lending agency for TION OF THE LABO DE OF TH� STATE OF CALIFORNIA RELAT" LATH, INT.
the performance of the Work for which this permit Is Issued I ING TO WORKMEN' CO PENSATIO INS ANCE.
(Sec. 3097, Civ. C.). LATH, EXT.
SIGNATURE OF HOUSE NUMBER COR-
Lender's Name PERMITTEES J,- - RECT AND POSTED
ADDRESS
Lender's Address I FINAL
3 I JOHN F. LEWIS, PRINCIPAL STRUCTURAL ENGINEER
g I certify that I have read this application and state that the
above information is correct. I agree to comply with all County PLAN CHECK VALIDATION P ..� CASH PERMIT VALIDATION CK. MOCASH
0 ordinances and State laws relating to building construction, I r sand hereby thorize representatives of this County to entertr 7 ;1 FEB 2 3 9.6 5
m upon the a ve-mentioned property for insp ction purposes. t
Signature of Applicant or of Applicant or AgeW Date
h�° N 1 � -