HomeMy Public PortalAbout10684 ARROWOOD ST_Building_2/22/1991_add den with fireplace WORKERS'
a K ' COMPEN ;3
ins r �'ertifcafe of Workers' Compensat oInsuran o%TION DECLARATION
eebycertificate consent f
A P P L I CAT I .F O R BUIL I NG PERMIT
ip ,
tif�copy thereof (Sec. 3800, Lab. C.)
COUNTY O L ANGELES BUILDING AND SAFETY
,yNo. Company
BUILDING /Olf/O
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING /�
tion department. ADDRESS 0b 1' 4irrowood oy
CITY-7511012/e" C r - . .ZIP rte/ LOCALITY
Date Applicant NO. OF BLDGS.
21241
CERTIFICATE OF EXEMPTION.FROM WORKERS' SIZE OF.LOT NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE ASSESSORt.
nuc"yam
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK ��� PAGE!/�D PARCOY /
hundred dollars ($100) or less..) TEL _ USE ZONE MAP
OWNER 11 I/l 1.1p?�1I O�NO. NO.
I.certify that in the performance of the work for which this �[
SPECIAL
permit is issued, I shall not employ any-person in any manner ADDRESS gT Arrowhad CONDITIONS CL
so as to become subject to the Workers' Compensation Laws. may- � 0
2— ZV"I CITY / . ZIP.
UZ Date Applicant ARCHITECT OR TEL. 0
NOTICE TO APPLICANT; If; after makingthis.Certif ate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY Q
CONST. ZONE U
Exemption, you should become -subject to the Workers'
Compensation provisions of.the Labor Code, you must forth ADDRESSY d
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO.
Z
deemed revoked. CONTRACTOR oe NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
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
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ.:FTNO.,OF / NO. OF CHECK
License Number Lic. Class SIZE. IfJ / STORIES 1 FAMILIES ONE
7 ! VALUATION a o
Contractor Date DESCRIPTION OF WORK /�- i de NEW. ❑ _
3 Q ADD
�`� e $ poll,
I am exempt under Sec. ALTER EJ
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF �+
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. FINAL (� !
OWNER-BUILDER DECLARATION (PRINT). NO. � '(
I hereby affirm that I am exempt from the Contractor's License DATE
Law-for the following reason (Section'7031.5, Business and ADDRESS FINAL
.i.
Professions Code): PRESENT - B�r
J,a{fJj BUILDING
I, as owner of the property, or my employees with
ADDRESS
wages as their sole compensation,will do the work'and LOCALITY , 2-" _-!
the structure is not intended or offered for sale(Section. -"'"
❑' 7044, Business and Professions Code.). MOVING TEL.
I, as owner of the property, am exclusively contracting
CONTRACTOR NO.
with licensed contractors-to construct the project (Sec-
ADDRESS
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST. sl-+'. -- _-
CONSTRUCTION LENDING AGENCY. SET BACK YARD HWY PROP. LINE WIDTH �� a.. _!,_!_
I hereby affirm that there is a construction lending agency for HFRONT ' ,( 1 r bl";
the performance of the work for which"this permit is issued(Sec.•3097, Civ. C.).Lender's Name. LDMA Ref.Lender's Address Permit Fee
J
0 1 certify that I have read this application and state that the Issuance Fee / LDMA P/C# ,
above information is correct. I agree to comply with all County Investigation Fee
6 ordinances and State laws relating to building construction, Total Fee c-;2Cd LDMA Perm. #
a and hereby authorize representatives of this County to enter
aupon the above-mentioned propert for inspection purposes.
�z —q. SEE REVERSE FOR EXPLANATORY LANGUAGE j
Signature of Applicant or Agent Date