HomeMy Public PortalAbout9042 ACASO DR_Building_9/26/1986 WORKERS'COMPENSATION DECLARATION
herebyinsure, orairm afcertif carte ofave Worke s' Compennsat oa certificate of n Insurancef w A P P L I CATION_ -FOR BUILDING PERMIT
or d certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING-AND SAFETY
Policy No. Company BUILDING
O
Certified copy is•hereby furnished. FOR APPLICANT TO FILL IN ADDRESS qQ pL
EJ Certified'copy is filed with ffieco6nty building-inspec- BUILDING
Tion department. ADDRESS (
Date Applicant CITY /T /. ZIP LOCALIT �!
CERTIFICATE OF EXEMPTION FROM WORKERS" NO.OPBLDGS. �� NEAREST
COMPENSATION INSURANCE SIZE OF LOT• NOW ON LOT CROSS,ST.
(This section need not be completed if the permit is for one ASSESSOR .
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
USE ZONE MAP
OWNER , TELL �� G
I*certify that. in the performance of the work for which this NO. f'T7
permit is issued, I shall not employ any pe on in any manner SPECIA �.
so as to become subject To the W om ion Laws. ADDRESS CONDITIONS . 0
�2 d� CITY ZIP _ v
Date Appli ARCHITECT TEL. O
DISTRICT :GROUP TYPE FIRE ESSED BY
NOTICE TO APPLICANT: I ter making this Certificate of 6-
ENGINEER NO. CONST. ZONE r UA
Exemption, you should ecome subject to the"Workers' ' �
Compensation provisions of The Labor Code, you must forth- ADDRESS v
with comply with such provisions or.this permit shall be - TEL. STATISTICAL CLASSIFICATION APT. CONDO:
deemed,revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC.- CLASS NO. Z// DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.-
Professions Code, and my license is in full force and effect. CITY CLASS B VALIDATION
SQ, 74.AoO,INC. OF _ - NO. OF _ CHECK
License Number Lic.Class' SIZE (,O STORIES FAMILIES ONE
• - � VALUATION.
DESCRIPTIO OF WORK iii✓ NEW - ❑
Contractor Date _ ADD a
I am exempt under Sec.
ALTER
B.BP.C. for this reason REPAIR ❑ a
USE OF
EXISTING BLDG. DEMOL
Signal APPLICANT TEL. FINAL
OWNER-BUILD DECLARATION PRWT NO.
DATE
. . - • Z t.:Z 421b
I hereby affirm that l am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINA
Professions'Code): PRESENT BY
p-� BUILDING
I, as owner of the property, 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). "' MOVINGTEL.
CONTRACTOR NO:
I, as owner of the property, am exclusively contracting CO -
with licensed-contractors to construct the project'(Sec-, ti
ADDRESS
tion 7044, Business and Professions Code).
REQUIRED- YARD HWY TOTAL SETBACK FROM - _ - , 5 5 1,2A
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH l ,`
I hereby affirm that there.is a construction lending agency for FRONT t :�' }' # o' 0 0 0 0 1
the performance of the work for which this permit is,issued P.L.
(Sec. 3097, Civ. C.). SIDE
28200
e Lender's Name �j * ` `_ 0 0
m 7/� LDMA Ref::.#> ° 2 8 2,�Q
P.C. Fee$ Permit Fee
Lender's Address �. 09.2 6=86
I 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 ` r�
ordinances and State laws relating to building construction, - Total Fee`
u and h b uthorize re es motives of this County to enter Z-v V LDMA Perm. #
upo ove-m ti e� erty for inspection purposes.
a /
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent - Date - - -_- •... .__ _. . - - - �i
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