HomeMy Public PortalAbout9034 JAYLEE DR_Building_5/29/1985_fireplace WORKERS' COMPENSATION'DECLARATION
I hereby affirm that I have a certificate of consent to self O O „ O O O D
insure or a aertificate'or Workers'Compensation Insurance, apG'd C Q�00H ..FQG3 C3M LD G�l`C [P IE Q 1
ora certified copy thereof (Sec.3800, Lab`. C ) - l - - -
a ; , 'COUNTY OF LOS ANGELES BUILDINCiAND SAFETY.
N
Policy,-No. Company -- - ( •'
BUILDING
Certified copy is hereby furnished ! FOR APPLICANT TO FILL-IN`_ ADDRESS e?Q. �.
Certified copy is filed with the county building in'spec- BUILDING i .
tioh department;``.' t'>' ? ' ADDRESS
Date' ' ' Applicdnt' CITY JeiF� ZIP LOCALITY $
_ -NO.OF BLDGS. _- F NEAREST
CERTIFICATE OF EXEMPTION"FROM'WORKERS' f
COMPENSATION#INSURANCE•' - SIZE OF LOT j7�j NOW ON LOT CROSS ST.
(This section.need not be'completed if the permit is for one - -- !' ASSESSOR •c ' >""{ '
_- ._ Cf _
hund[ed,dollars.($.100)or,less.); , TRACT ZSIS BLOCK LOT NO. MAP BOOK ? ' PAGE PARCEL
TUSE,zol - AP
t v OWNER 'r
certify that in the performance,of the:work for which this A
permit is issued, I sholl not employ any person in any mannerSPECIAL ®"
l s
ADDRESS CONDITIONS
so-as to become subject to iFie"Worker's'Com ens'tion Laws. -� V
�8ate y 9'. CIT-Y _ _.- ZIP_. all
VVJ, ,
Alp ARCHITECT OR TEL
NOTICE TO'APPLICANT: .If after'makt fhis`Certificate of DISTRICT GROUP TYPE FIRE _PROCESSED BY
R - ENGINEER NO. CONST. =`ZONE (�
Exemption•'•you 'should become subject'•to the Workers' ``
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Compensation prodisions of the Labor:Code, you mustforth- ADDRESS Y �-
with comply•',with such provisions or,this,,.permit.shall be ---• - - -- TEL �s
deemco'pl oked: },, STATISTICAL CLASSIFICATION t APT. CONDO. _
CONTRACTOR T -109- '
LICENSED CONTRACTORS DECLARATION ;• . -- - - - -- - LIC; CLASS'NO. DWELL.`UNITS
I hereby off irm.thatx6am licensed.under,provisions of Chapter 9 ADDRESS NO.
commencin with Section 7000 of Division 3 of the Business,and SEWER MAP
( g t t _ _ LI6::. .
Professions Code and my license is m full force and effect. CITY CLASS " VALIDATION
BK. PG.
SQ. FT. NO�OF NO.OF-. __ _ _CHECK !
License Number 6c.Class SIZE STORIES-.- FAMILIES ONE
❑ - VALUATION -
Contractor x Date 'DESCRIPTION OF WORK - NEW
ADD: � $
I am exempt.undet•Sec 4 :. .L�4.Q _ : ❑ 2 � 2 2 A
�, .
a, ALTER Y i
B,&P.C. for this reason REPAIR. Q $. _ #...o 67 ii o"o.�
Date: ;
y USE OF '
• - - o 0 2
EXISTING BLDG.
-•• APPLICANT TEL..
Sigriature FINAL
: a'6'0
OWNER-BUILDER DECLARATION
(PRINT) NO. _ DATE • t� 0 0 0 2&5"0'x
L hereby•affirni that I om.exempt from the:Coniractor's License.: _ r
Law.for the followtng•redsbn"(Section 7031 5 Business and ADDRESS FINAL
pro essions Co'de),' n r _ - PRESENT gyn _,• -
�. f -05-29 85
BUILDING "
I, as owner of the,piaperty, or my.employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY :.
7044; Business'and Professions,tode). "" MOVING' "" " ' TEL. "' - "
CONTRACTOR. NO.
I, as owner of-.the property, am exclusively contracting '- ' -Ar '
"with-licensed-contractors'to construct the-project'(Sec- ADDRESS ( _
tion 7044, Business and Professions Code).
Lam.. __ REQUIRED- TOTAL SETBACK FROM:.. _
CONSTRUCTION LENDING AGENCY - SET BACK YARD HWY PROP. LINE WIDTH' <
hereby affirm that there is d construction lending agency for FRONT
the-performance of the-work for which this.perrriit is issued P.L. - - - --
(Sec. 3097, Civ. C.). SIDE ' t
Lender's Name
LDMA Ref. # ....
P.C:fee$ •;--- --• Permit Fee - ._ .... l
Lender's.Address
:_I.certify that 1.have read this application and-state that the _- ' - Issuance-Fee V -LDMMA'P/C#
a above information is correct. I agree to comply with all County Investigation Fee , v
m - ordinances and State laws,relating,to.-building construction, , _ Total Fee LDMA Perm. # - )
a
u and,hereby authorize representatives of this County to enter / t
upon the above- ntioned property,for.inspection purposes. : t V
rj q � SEE REVERSE FOR EXPLANATORY LANGUAGE
--Signotvr Applicant.orAgent Date