HomeMy Public PortalAbout4800 BALDWIN AVE_Building_10/25/1982WOR<ERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self APPLICATIONinsure, or a.certificate of Workers'Compenstion Insurance, or O R BUILDING PERMIT
a certified copy thereof (Sec, 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.-- Company
copy y FOR APPLICANT TO FILL IN ADDRESS
Certif=<-'gid co is hereby furnished.
Certified copy is filed with the county building in ec- BUILDING l. 1
tion department. ADDRESS J v/. LOCALITY01
2,S—
NEAREST
Date ! ZApplicant CITY 1 t ZIP CROSS ST.
CERTIF ATE OF EXEMPTION M WORKERS' NO. OF BLDGS. I 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
NO.hundred dollars ($100)or less.) TRACT BLOCK LOT NO.
SPECIALTEL
CJ
I certify that in the performance of the work for which this
OWNER 41 L NO. CONDITIONS O
permit is issued, I shall not employ any person in any manner O \ ,
DISTRICT ))) GROUP TYPE FIRE PROCESSED BY U
so as to become subject to the Workers' Compensation Laws. ADDRESS YJ JxvrCONST. ZQpJE
qE I
Date Applicant
CITY ZIP /
STATISTICAL CLASSIFICATION APT. CONDO. U
NOTICE TO APPLICANT: If, after making this Certificate of
ARCHITECT TEL. Ly
Exemption, you should become subject to the Workers'
ENGINEER CLASS NO. DWELL. UNITS N
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
ADDRESSF,kv M
TEL
BK L PG (o z VALIDATIONdeemedrevoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION
commencing with Section 7000)of Division 3 of the Business and LIC.
QProfessionsCode, and my license is in full force and effect. CITY CLASS
79/ SIZ FT
STO IE FA
OF CHECK
License.Number Lic.Class SIZE STORIES ` FAMILIES ONE
JJ s Avmff NEW
Contractor JL[YYl'7N /T DC'Q.C 4Y-,fL p 1• DESCRIPTION OF WORK i,
I am exempt from the licensing rregqu"ireme is as am a
ADD
licensed architect or a registered professional engineer ALTER FINAL
acting in my professional capacity (Section 7051,
REPAIR
DATE
Business and Professions Code). - USE OFQ\/fes L_DEMOL FINAL
EXISTING BLDG. V1 11/ /
ByLic.or Reg. No. Date APPLICAN TEL. i
OWNER-BUILDER DECLARATION PRIN.T) NO.
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT
BUILDING t
I, as owner of the property, or my employees with ADDRESS
0,3 Awagesastheirsolecompensation,will do the work and22 7
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions.Code). MOVING TEL. 3 0 0 0 0 0 1
I, as owner of the property, am exclusively contracting
CONTRACTOR NO.
with licensed contractors to construct the project (Sec- 2:- 2875 0
tion 7044, Business and Professions Code). ADDRESS
i'
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 3-'0 0 287,500
I hereby affirm that there is a construction lending agency for FRONT
s ,
the performance of the work for which this permit is issued P.L.X025=82
Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
m P.C. Fee$pZJ '.! Permit Fee v P, Lender's Address
I certify that I have read this application and state that the Issuance Fee
above information is correct. I a ree to comply with all County Investigation Fee
0 ordinances and State laws re ting to building construction,wTotal Fee
and hereby a rize re t five of this County to enter
upon the a - ntio e r er ,for inspection purposes.-
t
SEE REVERSE FOR EXPLANATORY LANGUAGE
a •
ure of Applicant or Agent Dote s