HomeMy Public PortalAbout10544 DANBURY ST_Building_10/17/1988_aluminum patio cover WORKERS'COMPENSATION DECLARATION
YI 4V helegy affirm that I have a certificate of consent to self //p�� O �I7f� '(/� ///]�� M FOR
�I,�(� 1p� I�I��p��`/�� O gyp}�r��y�///'�L�
4 ilhnsure, or a certificate of Workers' Compensation Insurance, (/"1 P L�Qlr UlrH O Y V ll O R BO U�L M N V PLS I1�lIl T
or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑oi<y No D / V Company BUILDING n
Cert'rfied.copy is hereby furnished. FOR APPLICANT TO FILL IN a2 DIMJ 'lk
ADDRESS
0-iCertified'copy is filed with the county building inspec- BUILDING
lioon�department. - / ADDRESS .S [/ 14
Date�(%'�/ �GAppicant�rC �/J/�/ /nom CITY/ (� ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WMON FR WMO ORKERS' -Tr/�a(iE NO. OF MUGS. NEARESTpaji
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR '
hundred dollars ($100)or less.) TRACT d� do BLOCK LOT NO. MAP BOOK, PAGE PARCEL
TEL
USE Z¢(JE MAP -
I certify that in the performance of the work for which.this OWNER NO. PjY/` NO.
permit is issued, I shall not employ any person in any manner �' SPECIAL _ t
i
so as to become subject to the Workers'Compensation Laws. ADDRESS� CONDITIONS 0
T� � �Date Applicant CITY ZIP
ARCHITECT OR TEI.
NOTICE TO APPLICANT:should
If, after subject
this Certificate of ENGINEER NO. DISTRICT pUP TYPE FIRE PR SSED BY
Exemption, you should become subject to the Workers' - 'J/(\) CONST. I / ZONE V
Compensation provisions of the Labor Code, you must forth. ADDRESS " 6 r s+ 2 W
with comply, with such provisions or this permit shall be D-
deemed revoked. TEL.p STATISTICAL CLASSIFICAjION APT. NDO. N
CONTRACTOR NO.O -OI I Z
LICENSED CONTRACTORS DECLARATION !// I.C. CLASS NO. y DWELL. UNITS—
SEWER
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 7(�S S, /C NO. .5 0
(commencing with Section 7000)of Division 3 of the Business and Alt R LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY //T) {'/j�1.$ CLASS BK VALIDATION
�c-s/'J /;ms's SQ. FT. NO. OF. - NO. OF CHECK
License Number 15�V J'i Lic.Class v-/ SIZE ` 5 STORIES FAMILIES ONE !
Ti VALU ION U �
Contractor//Ehb/Y/EOate ZL/�� DESCRIPTION OF WORK NEW ❑, S D/)JT
❑
j40-ho'—
ADD (f v D I am exempt under Sec. """,/ /-y Um O ALTER
.BP.C. ❑
Bfor this reason �Y�/� REPAIR ❑ s
Date: USE OF _
EXISTING BLDG. DEMOI ❑ .
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO. - DATE
I hereby offirm that I am exempt from the Contractor's License - 9 2 5 A
Law for the following reason (Section 7031.5, Business and ADDRESS FI
see�e a e•�
Professions Coda): - � �� -
yla
❑ ,( e e &
1, as owner of the property, or my employees with BUILDING 6 6 3ADDRESS
wages os their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY •to - 6B635
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. ( (1171-8 8
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). _ t
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM xIbT.1.
SET BACK PROP. LINE WIDTH >
hereby affirm that there is a construction lending agency for FRONT -
he performance of the work for which this permit is issued P.I.,
(Sec. 3097, Civ. C.). SIDE
PA.
Lender's Name -..T.,_ __:_ _..,:...,. -,< ..-_ ...•:r -
�P-f /� LDMA Ref. M
m Lender's Address ^.P.C. Fee$ Permit Fee V '0T '
I certify that I have read this application and state that the Issuance Fee rot,So tLDN P/6q
a above information is correct. I agree to comply with all CountyI Investigation Fee 9� '
9 ordinances and State laws relating to building construction, Total Fee V • LDMA Perm. p
R and hereby authorize representatives of this County to enter _
uPon the above-mentioned property f inspection)purposes. - -
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent'�� Dote