HomeMy Public PortalAbout9058 ACASO DR_Building_4/21/1992 r' ,WORKERS' COMPENSATION DECLARATION y
affirm that
rtofconsent
Insurance,ttolAPPLICATION FOR BUILDING PERMIT
insure, or hate of WerkesCompeon
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING
❑ . Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN ADDRESS �O�'� CSG-Wit✓'-Q-D
❑ Certified copy is filed with the county building inspec- ADDRESS BUILDING
tion department.
CITY C� ZIP LOCALITY
Date Applicant /� NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT�X2-4V/ NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR p r/
(This section need not be completed if the permit is for one TRACT BLOCK I LOT NO. MAP BOOK PAGE ��� PARCEL
hundred dollars ($100) or less.) . TEL..
USE ZONE AP jl/ �—
I certify that in the performance of the work for which this SPECIAL }
CL
permit is issued, I shall not employ any person in any manner ADDRESS�D� /\ CONDITIONS 0
so as to become subject to the Workers'Compensation Laws. OV
CITY G ZIP
tY
Date Applicant ARCHITECT 0 DISTRICT GROUP TYPE FIRE P CESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER O. CONST.. E U
Exemption, you should become subject to the Workers' O /_D G 'ryr �� }�' 3 v t a
Compensation provisions of the Labor Code, you must forth- ADDRESS !i N
with comply with such provisions or this permit shall beTEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. z —
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 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 LIC. R
VALIDATION
�y/ <i i
and Professions Code,and my license is in full force and effect. CITY CLASS BK
SQ. FT. �l� NO. OF NO. OF CHECK -
License Number Lic. Class SIZE GT(/ STORIES FAMILIES ONE _ ? I?',
/
VA LU TION
f-t
Contractor Date
DESCRIPTION OF WORK �O/�/ NEW ❑ i -
.• _ � `� '-""
ADD
❑I am exempt under Sec. LTLRit
❑ Qd ;•s s- a--
B'.&P.C. for this reason � i EPAIR ❑ $
Date: USE OF D�` ?i�(� 10:1EXISTING BLDG. DEMOL
Si nature APPLICANT �.� TEL —0/,fFINAL /► - »""
Jk g OWNER-BUILDER DECLARATION (PRINT) DATE 9 '
I herebyaffirm that I am exempt from the Contractor's License
P ADDRESS /Y"t!� � FINAL
Law for the following reason'(Section 7031.5, Business and
Pro .ssionsCode): PRESENT By BU MING
-.•-
I, as owner of the property, or my. employees with ADDRESS
wages as their sole compensation,will do the work and d•>_z_j' ;i +':
the structure is not intended or.offered for sale(Section LOCALITY _•i- _--
7044, Business and Professions Code.) MOVING TEL. , s
r ert am exclusive) contractin
CONTRACTOR NO.
I as owner of the o _
❑ Y 9 •
with licensed contractors to construct the project (Sec- ADDRESS - _' ' ''
tion 7044, Business and Professions Code.) RQIRED >•`' ' .' y.
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTA PROP .ALINEFROM WIDTH
I hereby affirm that there is a construction lending agency for FRONT _ r.
the performance.of the work for which this permit is issued P.L. _
(Sec. 3097, Civ. C.). SIDE _a- €'�F �;_ 26;
P.L. _
Lender's Name. C
LDMA Ref. #
m P.C. Fee$ 0�,D Permit Fee �j C"! ir`G 144
Lender's Address l ,
a 1 certify that I have read this application and state that the ®• �� Issuance Fee J LDMA P/C#
o
8 above information is correct. I agree to comply with all County Investigation Fee i;a it_; ::y1;,.) •: +s
d ordinances and State laws relating to building construction, Total Fee !J LDMA Perm. #
a and hereby authorize representative of this County to enter
m upon t above- entioned property f inspection purp es.
a
d 2I SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Af Applicant or Agent Date