HomeMy Public PortalAbout9027 ACASO DR_Building_9/17/1986_room conversion, add & enlarge rooms 5-1
KERS'C',MPENSATION DECLARATION (l
,nS ertif carte of Worke rtComtpensotion`nsuran of APPLICATION: .FOR BUILDING PERMIT
or'o certified copy theroof (Ser-. 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
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS Gy
Date Applicant CITY /f% t ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' O. OF BLDGS. NEAREST i
COMPENSATION INSURANCE SIZE OF LOT 6-C A6 NOW ON LOT CROSS ST. �� //9 "�" �%/✓ v
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
Y P } EL' U ONE MAP / r
OWNER ( /
I certify that in the performance of the work'for which this � � � NO NO.
permit is issued, I shall not employ any person in any mannerG �/ �r SPECIAL IL
so as to become subject to the Workers'Compensation aws./j� ADDRESS_ CONDITIONS 0O
Date Applicant
� ZIP
/vG CITY � Gf�
ARCHITECT OR TEL. O
NOTICE TO APPLICANT: If, after making this Certificate of - — DISTRICT GROUP TYPE FIRE PROC SED BY �
Exemption; you should become subject to the Workers' ENGINEER NO. CONST., ZONE
LU
Compensation provisions of the Labor d
Code, you must forth- �V/
with comply with such provisions or this permit shall be ADDRESS r OU ��
deemed revoked. —_ TEL STATISTICAL CLASSIFICATION APT. CONDO. Z
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIG CLASS'NO. DWELL. UNITS
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 LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK 'PG 7� VALIDATION
SQ. FT. NO.OF NO. OF CHECK
License Number Lic.Class SIZE STORIES l FAMILIES ONE
❑ VALUATION �3x �
DESCRIPTION OF WORK [ r ; t NEW
Contractor Date $
DU ,
❑ I am exempt under Sec. Lr ]�ti/ �J�J ADD
J 9 r ALTER ❑
B.&P.C. for this reason ��l ' �� 41'4/Z L� tel✓ PAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOII ❑
Signature APPLICANT ) TEL. j�
g (PRINT) Gl� C 1- NO. 2,0,57-- ' FINAL ;
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License /
Law for the following reason (Section 7031.5, Business and ADDRESS �� ' a
Prof sions Code): PRESENT
BUILDING ;954i,9A
I, as owner of the property, or my employees with ADDRESS a o 0 0 0'1
Wages as their sole compensation,will do the work and
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 a 1 8 1, 1 .3:;
with licensed contractors to construct the project (Sec- ADDRESS 9, 1 `8
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM
'CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE dWIDT11
hereby.affirm that there is a construction lending agency for FRONT '
the performance-of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
m LDMA Ref. #
Lender's AddressP.C: Fee$ Permit Fee I certify that I have.read this application and state that the Issuance Fee Q- LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee iJ /, LDMA Perm. #'.
v and hereby authorize representatives of this County to enter
m upon the above-mentioned prop rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE 4
Signature of-Applicant-
or Agent Date'