HomeMy Public PortalAbout9034 JAYLEE DR_Building_3/26/1985_master bdrm bath,fam rm ` WORKERS'.COMPENSATION+DECLARATION
insure bor'afcertif catte of WorkersrTCompensat ons Insuron eificate of conent to lf L/�1 �: O C.!/11 LI B U V=. O 0 d D Gil C p C G3G�ly ff
or a certified copy thereof(Sec.,3800 Lab.
-COUNTY OF LOS-ANGELS' BUILDING"AILD SAFETY
Policy No Company BUILDING:
0
Certrfied copy is hereby:furmshed FOR`APPLICANT TO FILL IN'; ADDRESS
Certified copy is.filed with he'county building"insF. BUILDING r c i
tion department ADDRESS ��. JY L.E.0 LOCALITY ' G'( 1 r
< L ` •• NEAREST`''
Date' Appl icdnt CITY 1 .r� {r tL'' .C l,i',1. ZIP `. `7 5. CROSS ST..'.. 4 r ' . .
CERTIFICATE:OF EXEMPTION:FROM WORKERS" NO: OF BLDGS: ASSESSOR
COMPENSATION.INSURANCE
SIZE OF LOT 7 NOW ON LOT MAP'BOOK PAGE PARCEL ,
(This section need not be completed if.the permit is for one /�%SuAcf o USE ZONE MAP �1
hundred'dollars ($100)or less.) ' TRACT �8 BLOCK LOT NO. 1 �_ I NO. Zt)l
TEL.
/ CONDITIONS IL
4r DISTRICT, .GROUP TYPE FIRE PROCESSED BY, Q
permit is issued, I shall not employ any person in any manner ADDRESS rJ jK}�"✓(� A g OV G ST / CONST.' ZONE 6J
so as to become subjectto the Workers'Compensation Laws: J /�X /
CITY E V`1 e L 6 e(l ZIP `✓"!! V
Date Applicant' U STATISTICAL CLASSIFICATION APT. CONDO..
NOTICE TO APPLICANT: If, after• making.this Certificate-of ' ARCHITECT OR TEL.:
Exemption, you should become subject to the Workers'' ENGINEER NO.` CLASS�NO. ln
�� DWELL. UNITS UJ
Compensation.provisions of the Labor Code,•you must forth- ADDRESS SEWER MAP
with •comply with such provisions or.this .permit shall be _
TEL'
CONTRACTOR 1.V
deemed revoked: pS Q BK. PG, VALIDATION
2 NO,'ZO ZO p�f
LICENSED CONTRACTORS DECLARATION 1 LIC. ``''
1 hereby affirm that I-am licensed under provisions of,Chapter 9 ADDRESS NO. VALUATIONV��
(commencing with Section,7000)of-Division 3 of the Business and LIC
Professions Code, and my license is n-full force and effect. CITY CLASS $
SQ. FT.,dg5/ NO.OF NO. OF CHECK _
License Number, Lic.Class SIZE ISTORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK AXD I' NEW
El
JEW
D 1 am exempt under SecBcy owyA4 _ 3 T- ADD. 1 7 4 4 A
• - ALTER 0 FINAL /•
B.&P.C. for this reason F¢}Ix1 L (L�0 DATE
REPAIR 0 #.0
USE OF FINAL
Date: EXISTING BLDG. E S I £ C — DEMOL Q
Signature i APPLICANT TEL. By rte" )'0 2 2 Q Q
Qa
OWNER-BUILDERDECLARATION PRINT. NO.
o"o Z 2 S O
I hereby affirm that i am exempt from the Contractor's License 1(14 D6
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions'Code): ' • PRESENT
0-326t&5
BUILDING
I, as owner of the property, or my employees with ADDRESS
'wages as'their sole compensation,will do the work-and
the structure is not interided•or.'offered for sale'(Section LOCALITY
k
7044, Business and Professions,Co,'de). MOVING TEL. - _
I, as owner of the property, am.exclusivelycontracting CONTRACTOR NO.
_ with licensed contractors toconstructthe project (Sec- ADDRESS
tion 7044; Business and'Professions Code).
CONSTRUCTION LENDING AREQUIRED TOTAL SETBACK FROM EXIST.
GENCY SET BACK YARD HWY PROP. LINE WIDTH «.T
I hereby affirm that there is'a construction lending agency for FRONT l
the performance of the work for which this.permit is issued P.L.
(Seca 3097,Civ. C.). =SIDE
P.L.
e Lender's Name s..•`. - _
' P.C. Fee$ Permit Fee. -
Lender's Address V =i
I certify that l have read this application and state that the Issuance Fee
above information is correct:I agree to comply with.all County Investigation Fee y�
g
ordinances-and,State'laws reloting•to building construction, Total Fee. U
u and hereby authorize representatives of this County to enter
m upon the above=rimentio d property for inspection purposes.
o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o pp
®s
nt or. gent Date
i
' �