HomeMy Public PortalAbout4909 ARDSLEY DR_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent To self APPLICATION FOR BUILDING P E RM I T
insure; or a certificate of Workers' Compensation Insurance,
or erti i d co y t reof (Sec. 3800, L b.'C.)
j, �yh�ji COUNTY OF LOS ANGELES BUILDING AND SAFETY
y (/ 6��7 ompanyT'��
BUILDING
❑ Certified copy is hereby furnished: FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec BUILDING
nt.
ADDRESS
Date plicant f CITY' l-e , ZIP LOCALITY mow\ l_t
r. NO. OF BLDGS. NEAREST }} p
GE EXEMPTION FROM WORKERS'. SIZE OF LOT NOW ON LOT CROSS ST. le 1`, 1l1"1 J
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 (�(r NO.
I certify that in the performance of ihe'work for which this SPECIAL
permit.is issued, I shal l not employ any person in any manner ADDRESS SPEd
CONDITIONS
so as to become subject,to the Workers'Compensation Laws. • �
CITY ZIP '
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER DISTRICT GROUP. TYPE FIRE PROCESSED BY Q
CONST.s�� ZONE U
Exemption, you should become subject to'the-.Workers' ADDRESS .J•V �' d
Compensation provisions of the Labor Code, you must forth- ' Z
with comply with such provisions .or this permit shall be � TEL. 8}� STATISTICAL CLASSIFICATION . . APT. CON
deemed revoked. CONTRACTOR NO. / � j —
LICENSED CONTRACTORS DECLARATION LIC. r CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES �y NO. p 1,10
(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. CITYW. f/( CLASS BK. PG. VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Classy_ SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date' V DESCRIPTION OF WORK 5 e � NEW ❑ $ �/�
�/ ADD ❑ v ►
❑I am exempt under Sec. w W�l
ALTER 101
.kr•-••:- =
B.&P.C. for this reason
$
USE OF c REPAIR66
Dater EXISTING BLDG.
�E.S�� Crei DEMOL
Signature APPLICANT TEL. ) FINAL
(PRINT). /�1 NO. / /� - -•-• -._
OWNER-BUILDER DECLARATION DATE �V !`•__`@Et'_ = �` :m ' x
I hereby affirm that I am exempt from the Contractor's License
14
Law for the following,reason (Section 7031.5, Business and ADDRESS 7� FIN t_ �4) ;`,•'�;� ;
Professions Code): PRESENT ey / ;•ta -
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 LOCALITYoil,
7044, Business and Professions Code.) MOVING TEL. t31}}
❑ I, as owner of the.property, am exclusively contracting CONTRACTOR NO. t
with licensed contractors to construct the project (Sec- i y et,,sA rc:
ADDRESS
tion 7044, Business and.Professions Code.)
CONSTRUCTION LENDING AGENCY SETT REQUIRED
YARD HWY TOTAPROPSETBALINEFROM WIDTH
I hereby affirm that there is a construction lending agency.for FRONT r�
the performance of.the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.'
Lender's Name
n LDMA Ref. #
P.C. Fee$ Permit Fee
Lender's Address
o I certify that I have read this application and state that the Issuance Fee LDMA P/C#
0
8 above information.is correct. I agree to comply with all County Investigation Fee d^ Q�q
R ordina es and State laws relating to building construction, Total Fee - t , CI CJ LDMA Perm. #
a an er y authorize re esentatives of.this County Jo enter
u t above-7ntio property f inspe tion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of plicant or Agerf Date "