Loading...
HomeMy Public PortalAbout10550 DANBURY ST_Building_2/20/1986_balcony back of house WORKERS' COMPENSATION DECLARATION r .�':•' /�-/`�- M L��} R 1flf �rl��Up�'1/�� s, 1�'�p�r��(���Lg///-L�� hereby affirm than have o certificate of consent to self //]y IJ lkv��{I -MMM �U 0111 B LDO G PISIIUfI 7 �y insure, or a certificate of Workers' Compensation Insurance, llll 11 U _ �:J!/'"�1_ ora certified copy thereof(Sec. 3800, Lab. C.) - - COUNTY OF LOS ANGELES BUILDING AND SAFETY I r , • .. . Policy,No. - Company . O -Cernfied,copy is hereby furnished. FOR APPLICANT TO FILL IN ` BUILDING _ ADDRESS Ceriified copy is filed with the county' building inspec- -' BUILDING • tion department. ADDRESS 10 J�-6^O q'v b" x Date Applicant •t' n CITY e 41 12 i e ci T ZIP LOCALITY T E C! r CERTIFICATE OF EXEMPTION FROM WORKERS' —' - NO. OF BUDGET. - NEAREST _ ' - •• COMPENSATION INSURANCE -. SIZE OF LOT NOW ON LOT CROSS ST. (This'section need not be completed if the permit is fomone - - - - - - -- - -- - ASSESSOR '- - - hundred dollars ($100)or less..). . - TRACT BLOCK LOT NQ MAP BOOK' PAGE PARCEL TEL. USE ONE - MAP ' I certify fhaLin`the performance of the work far% ¢h this OWNER =III 'r�YC NO. NO. Y permit is Issued, I'shall not employ any person in y manner _ A SPECIAL so as to bet me s bject to the Workers ;mp sation Laws. ADDRESS' N �r CONDITIONS V 70 e1T ... CITY e.M _C _ ZIP - - \ _ _. - 0 Date Appiccin ARCHITECT OR - TEL O NOTICE �T AP ]CANT: If, er making this Certificate of ©' DISTRICT GROUP TYPE, FIRE PROLE SED BY r ENGINEER NO.7/ CONST. ZONE U Exemption, you should b come subject- to the Workers' - - p\ D yl Compensation provisions of the Labor.Code, you must forth- gODRESS V t y with comply with.such provisions or.this.permit.shall be _. _ _ .. . _ TEL.-- - .STATISTICAL ClAS51F1 ATION APT, CO DO.• #A deemed revoked'.-y, CONTRACTOR NO. ) LICENSED CONTRACTORS DECLARATION - - C_- - --- -- CLASS No. DWELL UNITS_ hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �' -I o d O. - (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 e / G ) CLASSBK - PG, - - ' VALIDATION c' SO. FT. NO. OF NO. OF _CHECk License Number Lic.Class SIZE Q STORIES C- FAMILIES I ONE A NEW _ VALUATIONS DESCRIPTIONOF WORK C❑oniroctor Date ADD $ , am exempt under Sec. .0 ALTER ❑ �3-9-5 5 A B.BP.C. for this reason e 05e REPAIR O $ # s e e e 23 Date: -" USE OF DEMOL EXISTING BLDG. - - - Signature _. - APPLICANT_ _. - TEL FINAL / ,� 'I • - 6.5 3 4 OWNER-BUILDER DECLARATION (PRINT) NO. -� _ DAT G_ --g. - - - I hereby affirm that I am exempt from the Contractor's License • ^ - 653 4 Law for the following reason (Section 7031.5, Business and ADDRESS FINA Pssions:Code):.. - .-. ._ PRESENT _ - - �rL89./ O 3 t8 6. BUILDING N U I, as owner of the property, or my employees with ADDRESS wages cis 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 ' - 'l TEL. - - -' I, as owner of the property, am exclusively contracting CONTRACTOR .' with licensed contractors toconstructthe project (Sec- ADDRESS L t -54 0 7,3 A-- tion 7044, Business and Professions Code). - CONSTRUCTION LENDING AGENCY - REQUIRED ygRO HWV TOTAL SETBACK FRum - �� _ -. r# s e • a •-�, SET BACK PROP, LINE WIDTH - .1"hereby affirm that there is a construction lending agency-Tor FRONT ' " ^ 87,38' the performance of the work for which this permit is issued P.L. - - -- - - - -- - _ I • ----, (Sec. 3097, Civ. C.). SIDE ' P.L. 8 7.3'8'0 Lender's Name - '- s MA -8.6 DReL # p22p m - - P.C. Fee$ s 3 - Perm t Fee �� - - - - --- '- - Lender's Address > I certify that I.have recidJhie dation and state that the Issuance Fee LDMA P/C#- - - - --- a above information is corr.CirI ree to comply with all County ,Investigation Fee ordinances and Ste _I citing to building co struction, .. _ - - Total Fee- LDMA Perm.'#'• - - and hereby authorize re sentatives of this my to enter - m upon the a ve=mens' ed property for pection purpose . } SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Applicant or Agent- - Date