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HomeMy Public PortalAbout9072 ACASO DR_Building_10/7/1980_ ORKERS',COMPENSATION DECLARATION - (hereby affirm that I'have a certificate of consent self � APPLICATION FOR BUILDING,-PERMIT '•, insure,orp certificate of Workers'Compenstron Insurance,or ` ' ' a certrf!,ed copy thereof(Sec 3800, Lab C ) t ` � COUNTY OF LOS,ANGELES BUILDING AND SAFETY .Pol c- 'No Company - - A ILL�JJj1 Certified copy is hereby furnished FOR APPLICANT TO FILLrIN ADDREING SS O- "Z Certified copy is filed,with'the county building inspec- BUILDING//Q 72 Q (/J r e-- tion tion department ADDRESS `"�( t e r LOCALITY 1 ""Dote • Applicant' - CITY (-` 4F ZIP [ ( CROSSNEARESST CERTIFICATE OF EXEMPTION FROM WORKERS' NO OF BLDGSASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK • PAGE PARCEL (This section need not be completed if the permit is for one USE ZONEh MAP hundred dollars ($100)or less ) - TRACT BLOCK LOT NO NO y `�` Q TEL SPECIAL d IHcertify that in the performance of the work for which this OWNER / `p` � ,r NO ����� CONDITIONS Q permit is issued, 1 shall not employ any person in any manner ADDRESS B� Cin �.� DISTRICT GROUP TYPE FIRE PRO SFD BY so_as to become subject to the Workers'Compensation Laws d �� CONST / ZONE Mg O t� .�j G �7 +• CITY I ZIP ( ( � 0 Date Applicant w , STATISTICAL CLASSIFIC TION APT JC0NDO U `NOTICE TO APPLICANT If, after making this Certificate of ARCHITECT OR TEL W ENGINEER NO I CLASS NO DWELL UNITS Exemption, you should become• subject to the Workers' - N Compensation provisions of the Labor Code, you must forth- ADDRESS 1 ' SEWER MAP ? . with comply with such provisions or this permit shall be' ///�/, VALIDATION deemed deemed revoked CONTRACTOR NO BK " ' PGr y o., ' LICENSED CONTRACTORS DECLARATION LIC - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION t (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code, and'my`license-rs in full'force and effect CITY CLASS $l d©Q s SQ FT INC, OF NO OF CHECK License Number Lrc Class SIZE STORIES IFAMILIES ONE -• " , Contractor � Date DESCRIPTION OF WORK 1 /7 J• b b(T-1Q NEW $ ❑ , - I ADD I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer . , ALTER ❑ FINAL ❑ 7 my professional capacity (Section 7051, REPAIR QZ5 i acting in Business and Professions Code) USE OF. r DEMOL i FINAL 1. EXISTING BLDG ❑ By Lrc or Reg No Date APPLICANT TEL _ •� - t ' OWNER-BUILDER DECLARATION (PRINT) NO F ' I hereby affirm that I am exempt from the Contractor's License L-aw for-the following reason (Section 7031 5, Business and ADDRESS ��reir PRE ENof the property, or my employees/with ADDRESS sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section 7044, Business and Professions Code) MOVING TEL _ 2•r4 9,9 A ' F_J 1, as owner of the property, am exclusively contracting CONTRACTOR NO e with licensed contractors to construct the project (Sec- rDRE r r # o e o • e - tion 7044, Business and Professions Code) TOTAL SETBACK FROM EXIST J CONSTRUCTION LENDING AGENCY YARD HWY PROP LINE WIDTH 210 - 7-0.00 I hereby affirm that there is a construction lending agency for • ' the performance of the work for which this permit is issued `o 0 o'7,0,Q 0 (Sec 3097, Civ C )Lender's Name Q0;�-86 Permit Fee _ Lender's Address , I certify that I have read this application and state that the Issuance Fee `r aabove information is correct I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Toto l'Fee ' 67 and hereby authorize represent tives of this County to enter up t ove-m ntion for inspection purp ses , < X SEE REVERSE FOR EXPLANATORY LANGUAGE o t t or Agent Signature of Ap Dote i ®s