HomeMy Public PortalAbout5345 PAL MAL AVE_Building_12/10/1984WORKERS COMPENSATION DECLARATION 1
hereby affirm that I have ccertificate of consent elf APPLICATION FOR BUILDING PERMIT LIIS
insure, or a certificate of Worr kers Compensation Insurance
or a certified copy thereof (Sec 3800 Lob C )
PolicyNo "/na7 Company S-A-rc wNV
COUNTY OF LOS ANGELES BUILDING AND SAFETY
0,,,, //Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS L
ertrfied copy is filed with the county building inspnc- BUILDING n L
I
d amen ADDRESS LOCALITY
Date phcanr /nf Sl/D.C/ 13f.+ CITY nP NEARESTcRosssr
TIFICA EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE
SIZE OF LOT 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 nto NO l
I certify that in the performance f the work for which this -
AL
OWNER S/ NO
CONDSPECI
ITIONS d
permit is issued, sholl not employ ny person rn any manner
DISTR GROUP TYPE FIRE PROCESSED BY O
so as to become bject to the Wm Compensation LowsADDRESS
CONST ZONE V
O 0
Date Applicant
CITYZIP
OR
ZIP
TFl
S TI TICAL IF TION PT CONDO O
NOTICE TO APPLI If, cher Makin thin Certificate of ENGINEER NO CLASS NO.,DWELL UNITS_ W
Exemption, you shou become subject o the Workers G
Compensation provisro f the Labor Code ou must forth ADDRESS SEWER MAP
with comply with such visions or this rmit shall be
deemed revoked CONTRACTOR v BK PO VALIDATION
LICENSED CONTRA ORS DECLARATION LIC
I hereby off inn that I am licensed under provisions of Chcpter 9 ADDRESS 100,_J, C°' NO VALUATIO
OcommencingwithSection7000)of Division 3 of the Business and LIC
Professions Code, and my license is in full force and effect CITY CLASS Pilo/
J SO FT NO OF NO OF CHECK
License Number s 3 d Lrc Class 19 /
Z
SIZE STORrES FAMILIES ONE
IYIf."/A AJ Bfi,/g.L 4/J ti/ NEW C1 $ContractorpESCRIP110N OF K
0 I am exempt er Sec
A
i ALTER FINAL
B AP C for this r son REPAIR DATELa O
USE OF FINWats
EXISTING BLDG B
SignatureAPPLICANT TEL
OWNER-BUILDER CIECLARATION PRIM NO
I hereby off irm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 S Business and
Professions Code)C 4 4 5 5 A
BUILDING
1, as owne the pro m my em oyees with ADDRESS
wages as the sole compo hon,w lido a work and Zi.,.17
the structure i of intended offered for le(Section LOCALITY 5 9 J I7041, Business Profession Code) MOVING TEL
I as owner of th ropeny, am clusively ntrochng
CONTRACTOR NO
with licensed con on to cons the pro act (Sec-
IF,
09 27-84
hon 7041, 8uaness Professions ode)
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY SE7 BACK YARD HWY PROP LINE WIDTH
poolherebyaffirmthatthereisoconstructionlendingagencyfmFRONT
the performance of the work for which this permit is issued PL
Sec 3097, Civ C ) SIDE
6 PL
Lender s Name
6 P C Fee$ Penna Fee T
Lender a Address
I certify that I have read this application and state that the lawonce Fee
above information is comect I agree to conriply with all County Investigation Fee
ord ancas or mStateIrelatconstruction, Total Fee
a ere u/Fiortz unry toe ter
th a ve-roe puu
SU REVERSE FOR EXPLANATORY LAI
i40'
s 0
p kont or Agent
s