HomeMy Public PortalAbout9027 ACASO DR_Building_4/13/1982_patio enclosure WORKERS' COMPENSATION DECLARATION
i re affirm that have a certificate of consent to self APPLICATION-. FOR BUILDING PERMIT
insure, or a certificate of Workers'Compensfion Insurance, or
a certified copy thereof (Sec. 3800, lab. C.) I
COUNTY OF LOS ANGELES BUILDING AND SAFETY
41-"p-olicy No.-C=-)�41 3-S/Company <15TA-TIV- R- Al
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 67 ® 9_ 7 d
ADDRESS i
Certified copy is filed with the county.,building inspec- BUILDING
tion'deportment. ADDRESS �J- LOCALITY
�.. 17/!-
9-0
sem NEAREST t\�
Date Applicant CITY - ZIP v CROSS ST. �J N
CERTIFICATE OF EXEMPTION FROM WORKERS'. O. OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE I PARCEL
USE ZONE MAP
(This section need not be completed if the permit is for one Q
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO.
/ TEL.
• ' CONDITIONS
permit is issued, I shall not employ any person in any manner DISTRICT GROUPADDRESS TYPE FIRE PROCESSED BY V
so as,To,become subject to the Workers'Compensation Laws. � CONST. 1E
Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT.` CONDO.
ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate s ENGINEER NO. CL
Exemption; you should become subject to the Workers' CLASS NO. - � DWELL. UNITS CL
Compensation provisions of the Labor Code, you must forth- z
ADDRESS SEWER MAP
with comply with such provisions or this permit shall be ,
deemed revoked. aTEL.7 / VALIDATION
CONT 6ZST NO.S V 735 BK./Y PG,
LICENSED CONTRACTORS DECLARATION LIC.
I hereby.affirm that I am licensed under provisions of Chapter 9 ADDRESS 772 j-kWb¢ 4 . NO.39 kb 2 VALUATION
(commencing with Section 7000)of Division 3 of the Business and I LIC.
Professions Code, and my license is in full force and effect. CITY //qr) T CLASS � $
Gam' SIIZZEF�(C+ ST -RIDES FAMILOIES CHECK
License Number �/3 ,7 Lic.Class
NEW
ContractorDate DESCRIPTION OF WORK
❑ $
lam exempt from the licensing requirements as I am a . 4�%Jc ADD'
licensed architect or a registered professional engineer ALTER FINAL // 7
acting in my professional capacity (Section 7051, ❑ DATE
REPAIR
Business and Professions Code). USE OF FINAL
EXISTING BLDG. DEMOL ❑ By
Lic.or Reg. No. Date APPLICANT TEL.
OWNER-BUILDER DECLARATION (PRINT) 'NO.
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS
' Professions Code): PRESENT
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and 2 3 r6 2 4 A
the structure isnot intended or offered for sale (Section LOCALITY
7044, Business and Professions Code). MOVING TEL. # o o'o o o 1
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO,
with licensed contractors to construct the project (Sec- 2'O Io 5.2 O O
tion 7044, Business and Professions Code). ADDRESS
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. �o io o 52 O O
CONSTRUCTION LENDING AGENCY SET BACK v
PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency-for FRONT
the performance of the work'for which this permit is issued P.L. Q 4, 1 3'_82
(Sec. 3097,'Civ. C). SIDE
P.L. .
Lender's Name
W
Lender's Address P.C. Fee$ Permit Fee 1415
w I certify that I have read this application and state that the' ssuance Fee �!
aabove information is correct. I agree to comply with all County Investigation Fee �Pl
0 ordinances and State laws relating,to building construction, Total Fee
an y u u I I I I tives of this County to enter
n e a o ti' ection pur ses. Ve"
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