HomeMy Public PortalAbout5325 ZADELL AVE_Building_11/13/1992_ WORKERS' COMPENSATION DECLARATION I;
hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRIESS 'NG ��
❑ Certified copy is filed with the county building inspec- FADDRE
2 J�
tion department. 7 v J (3y
Date Applicant ^ ZIP e (J LOCALITY60.OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR <7r.J�v(This section need not be completed if the permit is for one BLOCK LOT NO. MAP BOOK dc7 PAGE �d� PARCELhundred dollars ($100)or less.) TIL• USE ZONE MAP '/ y Sa3 NO. 'T 7/LJ�o�/.I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner /�KsL _ SPECIAL }a
'C: CONDITIONS O
so as to become subject to the Workers'Compensation Laws. „^ 1 U
CITY G ZIP (rfJ " U
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE
Exemption, you should become subject to the- Workers' v w
Compensation provisions of the Labor Code, you must forth- ADDRESS le-5 r 3 a-
v7
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. CLASS NO. DWELL.UNITS
LICENSED-CONTRACTORS DECLARATION ADDRESS NO.
I hereby affirm that I am licensed under.provisions of Chapter 9 LIC SEWER MAP
(commencing with Section 7000)of Division 3 of the Business CIN CLASS
and Professions Code,and my license is in full force and effect. BK.. PG. VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class I SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑
El $ +
y�� ,
I am exempt under Sec. �r ADD ElA TER ❑
B.BP.C. for this reason AIR ❑ $
Date: USE OF G1�� L ❑
EXISTING BLDG.
Signature APPLICANT TEL. FINAL
;•tt^
OWNER-BUILDER DECLARATION (PRINT) NO. DATE ��"��9 �:••vf =^'
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and I ADDRESS FINAL
Professions Code): k PRESENT By �j•� ; _
tL I, as owner of the property, or my employees with BUILDING wages as their sole compensation,will do the work and I ADDRESS ;I_j IR
l ,,_, oj,
the structure is not intended or offered for sale(Section I LOCALITY - -T
7044, Business and Professions Code. I MOVING TEL. r �;i- '}' i; t;e
;
❑ 1,as owner of the property,am exclusively contracting CONTRACTOR NO. I -,-
with licensed contractors to construct the project (Sec- ADDRESS i� NK I1�
tion 7044, Business and Professions Code.) j
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
theerformance of the work for which this ermit is issued P.L.
(Sec. Civ. C.). p SIDE U:iii =-M
P.L.
Lender's Name p p
B P.C. Fee$ Permit Fee LDNIP Ref. N
Lender's Address
' 1 certify that I have read this application and state that the Issuance Fee LDMA P/C N
3 above information is correct. I agree to comply with all County Investigation Feei�
ordinances and State laws relating to building construction, Total Fee lege, O LDMA Perm. N
and hereby authorize representatives of this County to enter
g upo ove-mentioned proper t r.nspectio n purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignaturepplicant or Agent Date i