HomeMy Public PortalAbout5302 ZADELL AVE_Building_11/18/1986_ WORKERS'COMPENSATION DECLARATION
re(;y affirm that I have certificate of consent to Self APPLICATION FOR BUILDING PERMIT �
insure, or a ceitificqle o{'Workers'
Compensation
pensation Insurance, '
or a certifii&dd copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES I BUILDING AND SAFETY
Policy Nom—A16Company Ow 4L6 BUILDING
F1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDINGRESS �At,�' A+/f
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS ,530 Z - LOCALITY G/ CA,
jNEAREST 7
Date t [JO Applicant CITY � � G �t�9• ZIP CROSS ST. /
CERTIFICATE OF EXEMPTION FR RKERS' 1 NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT 1 NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one U NE MAP —
hundred dollars($100)or less.) TRACT, BLOCK LOT NO. NO. 73
r TEL. r SPECIAL S•
I certify that in the performance of-the work for which this OWNER MA. . Kf/ NO. - I CONDITIONS @.
permit is issued,I shall not employ any person in any manner " j DISTRICT GROUP TYPE FIRE OCE SED BY O
so as to become subject to the Workers'Compensation Laws. ADDRESS 63Va -" Ave r C^ CONS ZONE U
CITY 4! Cl .A. ZIP Jr QPj O
Date Applicant' STATISTICAL CLASSI KATION APT. CONDO. 1-
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. 2/
Exemption, you should become subject to the Woikers' ENGINEER NO. CLASS,NO. DWELL.UNITS
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be TEL.emed revoked. CONTRACTOR �j a N0. BK. Alf v p/PG,1� VALIDATION
LICENSED CONTRACTORS DECLARATION I LIC.
I hereby affirm that I am licensed under provisions of.Chapter 9 ADDRESS a�( i.lJy NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code,and my license is in full force,and effect.' CITY 0014%T CM/WA C• CLASS ®"•) $ ,
s SQ;FT (�j NO.OF NO.OF CHECK
License Number Lic.Class SIZE �•f ISTORIES FAMILIES I ONE
Contractor u Date L DESCRIPTION OF WORK °11b NEW Cl $
❑
ADD
I am exempt and r Sec. I L1�o ��� .
•.- ALTE ❑ FINAL
B.BP.C.for this reasoREPAIR ❑ DATE
USE OF e,.,.
Date' EXISTING BLDG. / IL tW/f1�/C� DEMOL ❑ B
APPLICANT TEL.
AP / y
Signature I PRINT .004 -r NO.q(,D" I �J1
OWNER-BUILDER DECLARATION I � -? 'Vl
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 .5, Business and ADDRESS LAO' ..A66. e0VdI AN. ,
Professions Code): ' PRESENT .
❑ I, as owner of the property, or m employees m with y p BUILDING
ADDRESS \
wages as their sole compensation,will do the work
k and I '
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
❑ I,as owner of the property,am exclusively contracting CONTRACTOR \NO.
with licensed contractors to construct the project (Sec- ADDRESS ;?5966A
'tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWl' PROP. LINE �- WIDTH , # 0 0 0 • •,�
I hereby affirm that there is a construction lending agency for FRONT - 209, 25
the performance of the work for which this permit is issued P:L. �
tSec. 3097, Civ. C.). SIDE
'Pi L. 002001,255
? Lender's Name
3 P.C:Fee$ Permit Fee J I 1. 1 8`86
Lender's Address
I certify that I have read this application and state that the i Issuance Fee 1�p 'fes
above information is correct. I agree to comply with,all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee 2-0 .66
�
and hereby authorize representatives of this County to enter
upon The abo e.do d roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App is or Agent I Date ®s