HomeMy Public PortalAbout10554 DANBURY ST_Building_8/7/1984_sun deck WORKERS' COMPENSATION DECLARATION � C �I
I hereby affirm that f have a certificate of consent to self QPPUCAMN. .FOO R BUMONG PC�RMOT IISI
insure, or a certificate of Workers' Compensation Insurance, 0
or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
RCertified copy is filed with the,county building inspec- BUILDING ((iQ
tion department. ADDRE55[ OfJJ Ui . � LOCALITY
NEAREST
Date Applicant CITY ellZIP ;7V 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 ZONE MAI'
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO.
!',` TEL. (`�O v r I 'SPECIAL r
I certify that in the performaYJr
rk for which this OWNER (l fU�d NO. Z`Y!u CONDITIONS d
permit is issued, shall not emn in any mann° DISTRICT GROUPTYPE FIRE PRO ESSED BV soas to become5 ject to ths tion Law ADDRESS ROCONST. ZONEPile
Date/ ApplicCITY ZIP STATISTICAL CLASSIFICATIONAPT. CONDO. OARCHITECT OR TEL. �j /NOTICE TO APPLICANT: If, aaking this Certificate ENGINEER NO. V
Exemption, you should becubject to the Workers' CLASS NO.�DWELL. UNITSCompensation provisions of for Code, you must forth- ADDRESS SEWER MAP sq
with comply with such provisions of this permit shall be TEL Z
deemed revoked. CONTRACTOR NO. . BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION uC.
I hereby affirm that 1 am licensed under provisions of Chopter 9 ADDRESS NO. LUATION
(coAtrtiencing with Section 7000)of Division 3 of the Business and LIC �j n�
P fessions Code, and my license.is in full force and effect. CITY CLASS ✓✓UVJ L�
SQ. FT. AA O.OF F OF CHECK IV'
L ,nse Number Lic.Class SIZE 0V STORIES FAMILIES ONE z 2 9 3,9 A
S
Contractor Date DESCRIPTION OF WORK A-fiQ 2 NEW
❑ # e o s -'2 3
ADD
I am exempt under Sec. ALTER FINAL 2'-.- 37.50
B.BP.C. for this reason
REPAIR DATE❑ - 3750E
, v
USE OF DEMOL
Date: EXISTING BLDG. ❑ FINAL '
aY i-' 07, 24-84
Signature APPLICANT✓A,,,,��. \A ���//��.. TEL.
OWNER-BUILDER DECLARATION PRINT .Jn rYHLS /, {'ESL/ NO.
I hereby affirm that I am exempt from the Contractor's LicenseT �. /b ��0 ��� D
Law for the following reason (Section 7031.5, Business and ADDRESS `�J J A! - -
Professions Code): PRESENT
I, as owner of the property„or my employees with BUILDINGADDRESS
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. [.o'o fg}
E] es e p
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS O a107-84
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 constructionlendingagency for FRONT D.
the performance of the work for-which this permit is issued P.L,
.(Sec. 3097,.Civ. C.). SIDE..
P.L.. 7
Lender's Name -
Lender's Address PC, Fee$'- 3:2 Sd, 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 Fea •�� ,
g ordinances a tate laws relating ilding construction, Total Fee
u and ereby t Drize representaY es o4 his County to enter
up n ob - e ioned rop rty fo inspection purposes. +
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of Applicant or AgAt Date es