HomeMy Public PortalAbout5420 ACACIA ST_Building_4/21/1994_replace 3 windows WORKERS;COMPENSATION DECLARATION
I-hereby,affAn-'thaf"I hale--a 'certificate of consent'to self APPLICATION
.
` inter o a'certific'ate
?f'Workers'
.Compensation Insurance; « 4z® R I L I N G. P E RM I T
° yora er�d copy thereof'(Sec 3800, Lab',C ) a " `
' ' - " ` - 't" ' ) '1�" `' `', -ti COUNTY OFILOS ANGELES , BUILDING AND SAFETY', s _
Policy"No Company _'f" -
y ❑�r .ti� BUILDING
d coPYHfurnised FOR,APPLICANT TO'FILL-IN -� �❑ erfe
eESSS -f�-2Mc,
Certified copy is filed with the county building inspec_ BUILDING
t-• tion department , ADDRESS _5
74 Zn A CtA A-
.DZIPafpp7v'
licdrit,
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a _
_
LOCALITY r
CERTIFICATE OF EXEMPTION FROM WORKERS' = R « ` NO OF BLDGS' / ' t
NEAR-EST'
ST
'
SIZE'OF LOT '� 2' NOW ON'LOT CRr Joh!
='COMPENSATION INSURANCE i`,'- ' n/y
(•This``secTion need not be completed if the per"mitis for one TRACT t BLOCK" LOT NO "" Mqp ASSEgppK`�> a y' PAGE D`b ' PARCEL �� P
r hundred"dollars ($100),or less ) ,"• ` TEL
< �'w y+> i OWNER%} Tl7✓I� _ NO_ Y USE ZONE' MAP _'+ u
Ircertify that m the`:performance of:the work-for-which this - - "'. � NO,-"
a
ermit ls,issued, I shalltnot employ any person many manner r ` _ " Q - SPECIAL`^
P ADDRESS+ * I, CONDITIONS O
so as to become subject to the Workers' Com '; }
e I pensation Laws
CITY- ", a ,,_ z - ZIP' s. ..'- e . - - 'i Q �- U
Date t Applicant = r- ARCHITECT OR J" r
NOTICE-TO APPLICANT-If, afterzmaking-this Certificate`of t ENGINEER x
TEL
_ ,,,DISTRICT;_ .GROUP TYPE FIRE CONST ZONE PROCESSED BY- Q
Exemption,, you should become-subject to, thedWorkers'.,', ? s " a ^ w t w
Compensating provisions-of the Labor.Code,'you,must,fo�th- r ADDRESS' �� - - , V" " ¢ a
wee°ed re y_with such,provisonsu or this permit'shall be , / ,:,Z, A n i TEL O STATISTICAL,CLASSIFICATION - - APT CONDO N
;deemed revoked ,, H ._s CONTRACTOR (/YV hWr` .� Z ,
'LICENSED CONTRACTORS DECLARATION , { r LIC CLASS NO DWELL 'UNITS
`si I hereby affirm that I am licensed under provi'sion's of Chapter 9 ADDRESS NO _
(commenting with Section 7000)of Division;3 of tFie'Busriess R" - " _ LIC `SEWER MAP•
and Professions,Code,and my license_is in full force and'effect CIN " ^ CLASS, 1 '`! BK n'�.• ', p VALIDATION
r. SQ'FT NO OF NO OF CHECK
License Number` << Lic Class - SIZE ' STORIESFAMILIES "ONE Y "
nr. ti . ,VALUATION a y
Contractor '' Date t' 'p' DESCRIPTION OF WORK_ " NEW ❑
❑ w a P - ADD- ❑ -$ �0�/-
I am exempt under Sec a a' y� fJ"
B 8P C for this reason
4 _ _ 'ALTER» _ _ t ►S-j - K
V USE REPAIR r❑
Date
EXISTING BLDG 1 DEMOL;❑
YSignature APPLICANT TEL _ _ ••
OWNER-BUILDER DECLARATION (PRINT) 'FINAL
O» DATE
hereby affirm that Cam exempt from the Contractor's License •
V K Law for the following reason (Sectron'7031 5, Business and' ' ' ADDRESS `T- FINAL ' r, ''n ,
Professions'Code) ps PRESENT a' Lt B '
� t BUILDING, y.
7 1 hCJry I, as owner,"of the`property, or my>employees with~; ADDRESS Y = l
wages as their sole compensationwill do the work and' _ T '_
the structure is not intended or offered for sale(Section LOCALITY - ,h >�` ,; --,
7044' business and Pr _ - _<<:_
r,
ofe i -
ss ons Code MOVING' ,. .i
_ and,Professions r � �;- ., _TEL _ ,
°> El ) �, CONTRACTOR NO x <'is + ;, - - -M
j, as owner of the,property, am exclusively contracting i' -
with'licensed contractors-to,cc nstruct the-project (Sec- a ADDRESS
'r tion 7044, Business,6ncl Professions Code ), '' -
CONSTRUCTION LENDING-AGENCY r REQUIRED YARD- 'HWY -TOTAL SETBACK FROM EXIST
"SET BACK PROP-LINE WIDTH, '} '
'1 hereby affirrn°that there is a construction lending agency for. FRONT ;,= • Y,_' ''"t =wkt,�' „"._+ �,
the perform'6nce'of,the'work forXwhich'this permit is''issued PL-
(Sec 3097, Civ"'C ) z SIDE,W. i< %s e ,,, '
Lender's_Name -te_ , - P L<
LDMA Ref q,
Lender's Address P C Fee$ . Permit Fee'. `
r 11'
o I cer`tify'that'I�have read this application and"state that the 1 Issuance fee, }�%' LDMAIp/C
above information is correct I agree to comply with all County : x, Investigation Fee #,
ordinances and State laws relating to building construction, I Total Fee �O . '' LDMA Perm q
aand hereby'authorize,representatives of this County to enter
). upon the above-menti ed roperty for inspection purposes ' » - - •z - ', , -
'SEE REVERSE FOR-EXPLANATORY LANGUAGE " +m
`` Signature of Applicant or Agent ++ ,•D61e _`t ' t