HomeMy Public PortalAbout4947 ARDSLEY DR_Building__ WORKERS'COMPENSATION DECLARATION
r affirm I havecertificate of consent to Self APPLICATION FOR BUILDING PERMIT
insusure,, or a certificate of Workers' Compensation Insurance, t
or a certified copy thereof(Sec. 3800, Lob. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.lew Company
Certified copy is hereby furni ed. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
® Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS �� LOCALITY .r
NEAREST
Date /4 Applicant/��SS,„ els 4iko CITY ,.a ZIP CROSS ST.
CERTIFIC TE OF EXEMPTION FROM WORKERS' O. OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT X `.aj NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed'if the permit is for one USE ZONE MAP
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO.
TEL. SPECIAL
I certify that in the performance of the work for which this OWNER py 41 ,O/A NO.�'L- 1 ' �/ CONDITIONS eL
permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY O
so as to become subject to the,Workers:Compensation Laws. ADDRESS /Y p' d G- CONST. ZONE U
tm
Date Applicant CITY e,!f ZIP StMIST10 r`APT. CONDO.
ARCHITECT.OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of /
Exemption, you should become subject to the Workers' ENGINEER B. NO. CLASS NO. DWELL. UNITS LU
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP CA
with comply with such provisions or this .permit shall be TEL.
deemed revoked. CONTRACTOR G BK. PG, VALIDATION
?- LICENSED CONTRACTORS DECLARATION /� �f NO.
LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. dP`OC7 LUATION
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY Sg vV101d-a CLASS 15 /jw•
�j SQ. FT. NO. OF NO.OF CHECK
License Number - 9"� �J� Lic.Class SIZE S�f10 STORIES / FAMILIES / ONE
Pi/oHfi NEW ❑ $
Contractor l�ibC�.� G/ISSDate_ /L DESCRIPTION OF WORK
ADD
I am exempt under-Sec.
ALTER ❑ FINAL
B.BP.C. for this reason DATE
REPAIR [3
USE OF DEMOL
Date: FINAL
NAL
EXISTING BLDG. S � ❑
Signature APPLICANT TEL. /jl - y
OWNER-BUILDER DECLARATION PRINT ,moi¢ C �S NO. 7 -S�8
I hereby affirm that I am exempt from the Contractor's License 9/770 ,
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT
BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation;will do the work and i 6 0 l A
the structure is not intended or offered for sale(Section LOCALITY \
7044, Business and Professions Code).. MOVING TEL. j,"t 0 0 0 0 0
I, as owner of the property, am exclusively contracting CONTRACTOR NO. L o 3 0`6-7 G
with licensed contractors to construct the project (Sec- ADDRESS 0 0 3 0 6 7.�
tion'7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. C. 7. 1 ri_ (�
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.
(Sec. 3097,.Civ. C.). SIDE.
Fs.,PP.L. .
o Lender's.Name
S
Lender's Address P.C. Fee$ Perm ii Fee
i .
I certify that I have read this application and state that the Issuance Fee 16
_ 0
above information is correct. I agree to comply with,all County
Investigation Fee
g ordinances and State laws relating to building construction, Total Fee
u and hereby authorize representatives of this County to enter
m upon the above-mentioned property for inspection purposes.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent tate .®s