The URL can be used to link to this page

Home My Public Portal About5329 ZADELL AVE_Building_9/11/1991_ N(bRKERS' COMPENSATION DECLARATION y hereby affirm chat I have certificate of consent self APPLICATION FOR B U IL DI I'�fi O PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES M BUILDING AND SAFETY Policy No. Company ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y ADDRESS �3 al ❑ Certified copy is filed with the county building inspec- BUILDING 2 tion department. ADDRESS Z L Date 'Applicant CITY TGMLFUW ZIP I LOCALITY NO OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT — 12°Q-I Sor, NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR // (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK � � � PAGE �r�� PARCEV 5 hundred dollars ($100)or less.) TEL ``'' OWNER NO USE ZONE MAP H7� I certify that in the performance of the work for which this `' SPE permit is issued, I shall not employ any person in any manner ADDRESS H V / CONDITIONS a- so as to become subject to the Workers'Compensation Laws. O CITY ZIP Date Applicant ARCHITECT OR cm" No DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZO E F- Exemption, you should become subject to the Workers' d �C `'5 3 p. with comply with such provisions or this permit shall be T L• STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. a DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK PG D VALIDATION SQ. FT. , NO.OF NO.OF CHECK License Number Lic. Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK S@W NEW ❑ $ IQ` ADD , ❑I am exempt under Sec. ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. -HovED Signature APPLICANT TEL FINAL OWNER-BUILDER DECLARATION 1 N - _ L�l I herebyaffirm that I am exempt from the Contractor's License FINAL Professions Code): PRESENT By {' s BUILDING ^ti::_; °r ❑ I, as owner of the property, or my employees with ADDRESS l 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.) MOVING TEL. ❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. r-y with licensed contractors to construct the project (Sec- ADDRESS D='iAL 294 m 167 tion 7044, Business and Professions Code.) _ CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROPALINEFROM WIDTH °- Ihereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name $ 00/ 7 LDMA Ref.q O?.y P.C. Fee$ Permit Fee yi'yc Lender's Address 2 00 o I certify that I have read this application and state that the Issuance Fee �✓ ' LDMA P/C 9 above information is correct.I agree to comply with all County Investigation Fee q ordinances and State laws relating to building construction, Total Fee 4-2,/ 67 LDMA Perm. # and hereby authorize representatives of this County to enter upon the bove-mentioned pro erty for in i?LTi'on purposes. �� - SEE REVERSE FOR EXPLANATORY LANGUAGE Sig a ure of Applicant or Agen Date