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HomeMy Public PortalAbout10554 DANBURY ST_Building_3/27/1987_reroof V OgjKERS'COMPENSATION DECLARATION hereby affirm that I havecertificate of consent to self APPL9C AT90) H FOR o M9d�9H('G' PERM97 insure, or a certificate of Workers'Compensation Insurance, or a certified/copy thereof/Sem. 3800, Lab. C.) � �ony f�ld9/LIZ��wf/O COUNTY OF LOS ANGELES - BUILDING AND SAFETY PolicyN Z Certified copy is hereby furnished. - FOR APPLICANT TO FILL IN - ADDRESS �tJ S © Certified copy is filed with the cou ty building inspec- BUILDING / tion epartment. ADDRESS LOCALITY - / ��/J ,�jy///A NEAREST � �i Date 4 Applicant �'% CITY & ZIP CROSS ST. CERTIFICATE OF EXEMPTIO FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION I SURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE NE MAP hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. TEL. ''// �GjGG I SPECIAL >. I certify that in the performance of the work for which this OWNER NO. 7r� O/ CONDITIONS 11 DISTRIk GROUP TYPE FIRE P ED BY O permit is issued, shall not employ any person in any manner ADDRESS Q j,`c /a /1 CONST.V ZONE U so as to become subject to the Workers'Compensation Lows. v (_/AV K 2 J Date - Applicant CITY t ZIP STATISTICAL CLASSIF ATION - APT. ONDQ. Q NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECTOR TEL. q Exemption, you should become.subject to the Workers: ENGINEER NO. CLASS NO: 2 DWELL UNITS— IL Compensation provisions of the Labor Code, you must forth- ADDRESS - - SEWER MAP W with comply with such provisions or this permit shall be TEL `/32 deemed revoked. CONTRACTOR zvzvNO. '' F BK. LPG, VALIDATION LICENSED CONTRACTORS DECLARATIONLIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ( NO VALUATION (commencing with Section 7000)of Division 3 of the Business and / �//// < LIC Professions Code, and my license is in full force and effect. CITY Fri QS 1 <�B.j CLASS S D License Number Lic.Class SQ. FT. NO.OF NO. OF 'CHECK Number `///� SIZE STORIES FAMILIES ONE Contractor, '--''N-�• Dote /� DESCRIPTION OF WORK NEW $ ❑ I am exempt under Sec. ADD ❑ �� ALTER ❑ FINAL B.BP.C. for this reason - REPAIR ❑ DATE 7 USE OF DEMOL ❑ Date: EXISTING B G. FIN APPLICANT / TEL. ) T Signature PRINT J rG NO.d , SBf 7 OWNER-BUILDER DECLARATION - I hereby affirm that I am exempt from the Contractor's _ �.'.. �l-� Law for the following reason'(Section 7031.5, Business and ADDRESS w 7YlG — 0 6.7 5 6 A Professions Code): PRESE • s 99,, P, I, as owner of the property, or'my employees with ADDBUILDIN DR Sl 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 e • • c' 1, as owner of the property, am exclusively contracting CONTRACTOR NO. 3,27.-87 with licensed contractors to construct the project (Sec- - ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP, LINE WIDTH D - 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 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 a above information is correct. I agree to comply with all County Investigation Fee g a rdinances nd State laws relating to building construction, Total Feend hereb authorize representatives of this County to enter ' pon th ab ve-mentione pro erty for inspectio ur ses. - - o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App¢ant or Agent Date .®s