HomeMy Public PortalAbout5345 PAL MAL AVE_Building_6/19/1981WORKERS COMPENSATION DECLARATION
OIherebyaffirmthatIhaveacertificateofconsenttoself
insure or a certificate of Workers Compensnon Insurance or APPLICATION FBUILDING PERMIT
a certified copy thereof (Sac
pan
Lab C )
COUNTY OF LOS ANGE( BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnishedBUILDINFORAPPLICANTTOFILLINAppy
Certified copy is filed with the county building inspec BUILDING
Ion department ADDRESS IAT LOCALITY
NEAREST
Date Applicant CITY /-Zip CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT 2-MAP BOOK PAGE PARCEL
This section need not be completed if the permit is for one U ZO IE MA
hundred dollars ($100)or less ) TRACT ,.
E (f /
BLOCK Loi NOTEL
O rl /
r V NO 7
CIAL d
I certify that in the performance of the work for which Ihn4
OWNER CONDITIONS O
rs dd
STRICT GROUP TYPE FIRE E BYpermitisisseedshallno,employ an arson in any manner
ADDRESS i.[.-LL CONST ZONE
V
so m to becomq.sublect to the Wor Compe oiyi ws
Z CITY_r' 0/ ZIPxDateApphcant STATISTICAL CLASSIFICATION APT CONDO rj
NOTICE TO APPLICANT If after mokmg this Certificate of
ARCHITECT TEL J W
Exemption you should become subject to the Workers
ENGINEER NO CLASS NO fJ L DWELL UNITS_ d
Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP
with comply with such provisions or this permit shall be Z
deemed revoked
CONTRACTOR D-WR it14,16r=Qr BK pG VALIDATION
LICENSED CONTRACTORS DECLARATION
U"I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES-4 41aI LL ATION
ommenang with Section 7000)of Division 3 of the Business and
A pProfessionsCode
L
and my license is in full force and effect CITY fi — CLASS C6
SO FTO OF NO OF CHECK
License Number Uc Class SIZE STORIES FAMILIES ONE
DESCRIPTION OF WORK NEW
S
Conrrac,or Date
j wA 5 4 5 3 A
I am exempt from the licensing requirements as I am o Ll fZoGiN AW J
licensed architect or o registered professional engineer ALTER FINAL 21
acting m
d
professional capacity (Section 7051 i REPAIR
DATE
Business and Professions Code) E OF
r] FINAL 2 • • .35 9 8EXISTINGBLDGDEMOL
ByLicorRegNoDateAPPLICANTTEL 3 5 9 8 is
OWNER BUILDER DECLARATION PRINT NO
I hereby affirm that I am exempt from the Contractor s License 0 a28-81
Law for the following reason (Section 7031 5 Business and ADDRESS
Professions Code)
owner of the property
BUILDING
y 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 LOCALITY
7044 Business and Professions Code) MOVING TEL
1 as owner of the property am exclusively contracting
CONTRACTOR NO
with licensed contractors to construct the project (Sec
ADDRESS 9 5 4 5 4 A
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY REQUIRED YARD Hwv TOTAL SETBACK FROM EXIST
SET BACK PROP LINE WIDTH
1
I hereby affirm that there is a construction lending agency for FRONT 2 • 07000theperformanceoftheworkforwhichthispermitisissuedPL
Sec 3097 Civ C )
SIDEPL 7000u
Lender s Name
q p 0528-81
9 P C Fee$ a a Permit Fee
Lenders Address
G I certify Ida, I have read this application and state that the Issuance Fee s
above information is correct I agree to comply with all County Invesugmion Fee
ordmanc and State laws relating to building construction
and her authorize representatives of this County to enter
Total Fee
V
upon above ,ion'd roperty for mspectio purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnoture of Applicon,or Agent IF D&t,7 s