HomeMy Public PortalAbout5325 ZADELL AVE_Building_6/21/1991_ WORKERS' COMPENSATION DECLARATION
'I hereby a certificate
that I have certificate of consent to self
r ; ' APPLICATION FOR B U I L�+I N G P E RM I T
insure, or a certificate of Workers' Compensation Insurance,
or a ceiNified copy thereof (Sec. 3800, Lab. C.') COUNTY OF LOS ANGELES- ''BUILDII(IG AND SAFETY
Policy No._;4bQ�Company BUILDING
Certified copy is hereby furnished. /l'`�-�J/ FOR APPLICANT TO FILL IN ADDRESS '
Certified copy is filed with the county building inspec- BUILDING ��iV�
tion department. ADDRESS
Date G F ..cant CIN ZIP LOCALITY Ji �-,1 �'
Pp OF BLDGS. NEAREST
CERTIFICATE OF EXEMPT10 OM ORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION SURAN ASSESSOR �J
This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK r/�S 6 PAGE uPARCELX�
hundred dollars ($100)or less.) TEL' USE ZONE MAP �/�
3
OWNER `„fl NO. NO. �� �� / -
I certify that in the performance of the work for which this `aaa{���
SPECIAL >_
permit is issued, I shall not employ any person in any manner ADDRESS S,3 ^' J` �/ CONDITIONS a-
so as to become subject to the Workers'Compensation Laws. 11 7,.,, O
L
CITY 2W4 . tr e4 ZIP - U
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE
Exemption, you should become subject to the Workers' (/ ' / 3 U
Compensation provisions of the Labor Code, you must forth- ADDRESS j0 >� "� ��`2'�'- -�-�-a
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR e L LICO CLASS NO. UNITS
LICENSED CONTRACTORS DECLARATION ADDRESS NO
I hereby affirm that I am licensed under provisioris of Chapter 9 • SEWER MAP
(commencing with Section 7000)of Division 3 of the Business. LIC.
and Professions Code,and my license is in full force and effect. t CITY & T26 CLASS 'g BK PG VALIDATION
SQ. FT. NO. OF NO.OF CHECK
License Number �d�Lic. Class SIZE STORIES FAMILIES ONE VALUATION
Contractor�iw -LArM C'iEgicba}e DESCRIPTION OF WORK NEW 1:1 $
❑1 am exempt under Sec. ADD ►
ALTER 10
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF DEMOL ❑
EXISTING BLDG.
Signature APPLICANT TEL• FINAL
OWNER-BUILDER DECLARATION (PRINT) O.
DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS �� FINAL
Professions Code): PRESENT BY
❑ I, as owner of the property, or m em to ees with BUILDING -
P P Y. Y P Y ADDRESS ��_y;t e a
wages as their sole compensation,will do the work and
Act'.-
the structure is not intended or offered for sale(Section LOCALITY 7``j
7044, Business and Professions Code.) MOVING TEL. 101
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. i EME
with licensed contractors to construct the project (Sec- ADDRESS ,A 5 24
tion 7044, Business and Professions Code.) TOT,, _ _�t�l fig- „ ,.
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 5I„•�.Dr
I hereby affirm that there is a construction lending agency for FRONT �• oH ..
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lenders Name U', -
'/ ��� LDMA Ref. #
• P.C. Fee$ Permit Fee _
Lender's Address 7• i r�;:!
2 tl
I certify that I have read this application and state that the Issuance Fee �,J LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
3 ordinances and State laws relating to building construction, Total Fee J l'7 �y LDMA Perm. #
and hereby authorize.representatives of this County to enter
upon the above- oned property for inspection purposes.
0 8SEE REVERSE FOR EXPLANATORY LANGUAGE I JP
Sign r o A plicant or Agent Date