HomeMy Public PortalAbout4879 ARDSLEY DR_Building__ WORKERS' COMPENSATION DECLARATION
insure, oraa certificate of Workers' Compensation ffirm that I have a certificate of n eInsuran of APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
El /,n Y r ( Dr .•Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS [,{,� AJ
❑ Certified copy is filed with the county building inspec- FE
/��s� p'
tion department. y r "
LE GI T ZIP 1 eO LOCALITY
Date Applicant O. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' O X FZ NOW ON LOT CROSS 5T. yJ SCZ e-•� �
COMPENSATION INSURANCE ASSESSOR L�
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK O PAGE �/ PARCELS// 7—
hundred dollars ($100) or less.) 1 TEL. D , �7[ USE ZONE MAP
OWNER W r i L 14,A- Lit) NO.TIO%Q(J�ZOD NO.
I certify that in the performance of the work for which this R J SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS l" CONDITIONS t1
so as to become subject to the Workers'Compensation Laws. O
CITY ! G! ZIP / Q—!J U
Date Applicant ARCHITECT OR TEL.
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 �. /�3 3 ow
with comply with such provisions or.ihis permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
Z
deemed revoked. CONTRACTOR a /'J•e NO. DWELL. UNITS
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.�
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 1
and Professions Code,and my license is in full force and effect. CITY. CLASS BK. CT PG. c7 VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑ $
❑I am exempt under Sec. E,� �QQ Q ADD El (� ►
v` ALTER ❑ '
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANTPP'''' `` TEL.
OWNER-BUILDER DECLARATION. p��IIII Q//
(PRINT)Wttt LlNO010—�t70-�G FINAL
`/,, /� J�,�-��J •
I hereby affirm that I am exempt from the Contractor's License ADDRESS W5�� �'\
DATE
Law for the following reason (Section 7031.5, Business and FINAL
Professions Code):. PRESENT By ---�""
BUILDING '
❑ I, as owner of the property, or my employees with ADDRESS
'wages as Their sole compensation,will do the work and , -- '•�'-
;s
1
the structure is not intended or offered for sale(Section LOCALITY MOVING TEL.
.7044, Business and Professions Code.)
CONTRACTOR NO.
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- ADDRESS
x
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST. _
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH (.i `•- �;
1 hereby affirm that there is a construction lending agency for FRONT.
the performance of the work for which this permit is issued P.L. (.?#yjY ;_ o {_;
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name.
LDMA Ref. #
P.C. Fee$ Permit Fee i
Lender's Address _:? iIG
o I certify that I have read this application and state that the Issuance Fee �J• `' LDMA P%C#
8 above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee �✓ • LDMA Perm. # '
a and hereby authorize representatives of this County to enter
upon the above- entioned pro or inspection purposes:
r
t , /0 SEE REVERSE FOR EXPLANATORY LANGUAGE "
Signature of,Applicant o gent Date