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Home My Public Portal About9027 ACASO DR_Building_4/29/1982_wood burning fireplace WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATI O N f O L D I N G PERMIT insure, or a certificate of Workers'Compenstion Insurance, or a certified copy thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified co is hereby furnished. BUILDING -) ❑ copy y FOR APPLICANT TO FILL IN ADDRESS E�— Certified copy is filed with the county building inspec- BUILDING r tion department. ADDRESS Ir LOCALITY ! �!� 91J NEAREST Date Applicant CITY ZIP CROSS ST. (✓ CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR 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 ONE MAP ` hundred dollars ($100)or less.) TRACT!- LOCK LOT NO. NO. / TEL. SPECIAL I certify that.in the performance of the work for which this OWNER _ NO. CONDITIONS O permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE C ED BY V ADDRESS CONST. ZONE so as.to become subject to the Workers'Compensation Laws. :0 , / o Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO. V NOTICE TO APPLICANT: If, after making this'Certificate of ARCHITECT OR TEL. /�� L&J Exemption, you should become subject to the WorkersENGINEER NO. CLASS NO. DWELL. UNITS EL Compensation provisions of the Labor Code, you must forth ADDRESS SEWER MAP with comply with such provisions or this permit shall be deemed revoked. > TEL. VALIDATION (1I� %� , LICENSED CONTRACTORS DECLARATION CONTRACTOR N0BK. PG, I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and �IN Professions Code, and my license is in full.force and effect. CITY CLASS r �� LIC. $ SQ. FT. NO. OF NO, OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE NEW $ Contractor Date DESCRIPTION OF WORK ' OI am exempt from the licensing requirements as I am a. ,'I (- ADD licensed architect or a registered professional engineer ALTER F] FINAL / ]�p acting in my professional capacity (Section 7051, (f t/ f REPAIR DATE Business and Professions Code). USE OF a FINAL EXISTING BLDG. DEMOL B �. Lic.or Reg. No. _Date APPLICANT TEL. y 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 ADDRESS7J 8.7J,3 A Profes ions Code): PRESENT BUILDING # o'o 0.0 0 I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and 210 0 3(� 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. o;o�o 3(L Q O F with licensed contractors to construct the project (Sec- ADDRESS 0 ({ 2 9'_8 2' tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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.I. (Sec. 3097, Civ. C.). SIDE P.I. Lender's Name Lender's.Address P.C. Fee$ Permit Fee I certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter Total Fee / upon the b ve-mentione ope for inspection purpos a SEE REVERSE FOR EXPLANATORY LANGUAGE d Signature of Applicant or Ago, g Dat ©s I