HomeMy Public PortalAbout5426 ACACIA ST_Building_8/27/1992_New Garage WORKERS',COMPENSATION DECLARATION BUILDING
L
hereby � that I have'a- certificate of consen self
a certificate
A P L I CAT I O I� FOR- U I'L D I N O 'P E R11AIT
' iI'sure, or a certrflcate of Workers' Compensation Insurance, - +•• _ R _}
• or a certified copy thereof (Sec 3800, Lab',C`) d _ COUNTY OF LOS ANGELES BUILDING AND-SAFETY
Policy No 'Company
O Certified co"'Is hereb furnished y ' FOR APPLICANT TO FILL IN BUILDING r� /
PYr Y -'- I _ ° F ADDRESS
❑ -„Certified copy is filed with the county building inspec- BUILDING
ADDRESS
s tion department .• ~ �
Date Applicant r v CITY^ j �_� zIP �, y LOCALITY ' y
r pA NO OF BLDGS
CERTIFICATE OF EXEMPTION FROM WORKERS', SIZE OF LOT�'ll"��+�r'o ��j X 0 NOw ON LOT �RossSST
'COMPENSATION INSURANCE , I ASSESSOR p y
(This section need not be completed if the permit is for one TRACT 4 BLOCK' LOT NO MAP BOOK t O (/ PAGE �� PARCEL
hundred dollars ($100)'or less ) ` • ) TEL _ ,
'which -' OWNER YJ�(i �� NO' "' `- ^� USE ZONE NO ,
I certify that in the performance'of the wo'k for this « _ _
-permit is issued, I shall not employ any person In any manner ADDRESSPECIAL
— CONDITIONS ` a
t,so as to become subject to the Workers' Compensation Laws _ n O `
ZIP . x U
Date Applicant •i ARC HIT OR ,,//��,�,, TE 21 DISTRICT h GROUP TYPE' FIRE PROCESSED BY
,NOTICE TO APPLICANT__If,I after making this Certificate of ENG ER �li�TT�!v• uN0`� 3.�9Z�o3 CONST ZONE 0
,,Exemption, ycux should become subject to the Workers' i, p � 1” U
Compensation provisions of the Labor Code, you must forth- ADDRESS.«�3 .�`���� , IPL 5-,' -�`� a
with,comply'withsuch_provisions_or this, permit shall be TEL ICATION APT u)
a' deemed,revoked v CONTRACTOR'- R STATISTICAL CLASSIFCONDO- _ NO Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chdpter 9 ADDRESS NO
(commencingSEWER MAP
with Section 7000)of Division 3�of the Business _ - LIC,
and Professions Code;and my license is in full force and effect CITY CLASS BK PG VALIDATION
SQ FT NO OF NO OFCHECK
License,Nurnber Lic Class, SIZE STORIES FAMILIES ONE -
a y vVALUATION
R� DESCRIPTION OF WORK 6*hIP C� CO'OLP&C NEW -❑ ;S ��lJ 42c� `'�
Contfactor Y Date
El am exempt under Sec \ - NEf.IJ W'0 [�(�
ALTER,ADD 02'3- - ,
'❑ �
B&P C for this reason _ - AC
USE OF REPAIR,, a r ACCT■7a ,•
Date Is - • _ ,
EXISTING BLDG 151FIs- DEMOL;® 15307 7F 1L,
TEL
_FINAL-
Signature
APPLICANT
` v - (PRINT)` r - ' - � ' _ -
OWNER-BUILDER DECLARATION ' DATE
I hereby affirm that I am exempt from the Contractor's License• p� HT.
A '
ADDRESS
Law for the following,reason (Section 7031 5, Busine"ss and ! ',FINAL �Lt T■T
Professions Code)"- PRESENT "By`
wAM
BUILDING `t x ^ , 7�1■1�
5 2 ( r Y �` � a =
I, as owner of the property, or my employees with ADDRESS C A r~
LOCALITY
wages as their sole compensation,will do the work and �_r i e t . ITFJV
t
the structure is not Intended or offered for sale(Section �44 4}; - � �" � � � �� 784-31
70 „Business and Professions-Code ) MOVING - + - TEL - '' ��''i t t 'TOTAL
CONTRACTOR NO a ty `
`❑ I, as owner of The property, am exclusively contracting _1 y �1. :>, 4 �' t.�`�1 L 724.17
with licensed contractors to construct the'project Sec- \" ,r yL,.
tion 7044, Business and Professions Code ) I ( ADDRESS x� 4w ,���'� 1v
REQUIRED TOTAL SETBACK FROM EXIST' _ - ,' . 4[ �A` �' r fuA�t
r_ CONSTRUCTION^LENDING'AGENCY `\V1 SET BACK YARD HWY PROP LINE WIDTHI ^w`a \+ r , f1.f1 GE s111�
I hereby affirm that there is a construction lending agency for FRONT �+ v ,
the performance of the work fair which this permit is issued P'L" _ �r
(Sec 13097, Gv C ) SIDE
Lender's Name A�{ ,,y
2 t /y 1 LDMA Ref 5.1,�^ 1 F71 f ■a 1
3 1� PFee' ,
'Lender's Address PC Fee$ ermit
S__
I certify that I have read this application and state that the � Issuance Fee LDMA P/C#
above information is correct I agree to comply with all County '�,))) Investigation Fee l
ordinances and State jaws relating to building,construction, Total Fee ` j LDMA Perm #
a.
Rqeby authorize presentatives of this County to enter ab ve-me i ed property for Inspection purposes " t
3 _
7�_ « t Y SEE REVERSE_FOR EXPLANATORY LANGUAGE _ e
Signature of Applicant or Agent a Date y