HomeMy Public PortalAbout9189 JAYLEE DR_Building_5/7/1991_add to back of building �. �`� I • OIZK j, 'COMPENSATION DECLARATION f r )
�a:� L
; CO c7 (0 V FDo that
certificate
Iinsureor acertifcate of WorkersCompensaton nsuranc '
or a cer�fied'co,� thereof (Sec. 3800, Loll. C.) = COUNTY OF LOS ANGELES 7, ; BUILDINGARID SAFETY
Pobicy No. Company
BUILDING
❑ Certified copy is'hereby:furnished.. '. FOR APPLICANT TO FILL IN ADDRESS
- Certified copy is filed with the'county building inspec- BUILDING / e.
tion-department. ADDRESS `
CITY �' PRPM LOCALITY
.Date'` Applicant' O O BLDG .
NEAREST
CERTIFICATE
OF,EXEMPTION-FROM WORKERS' SIZE OF LOT �B NOW ON LO7 1 CROSS ST
COMPENSATION INSURANCE' !!jj ASSESSOR tom;
(This'section need not be completed if the permit is for one TRACT BLOCK LOT NO. I d` I
3 � .MAP BOOK� '�- PAGE l/'� PARCEL
hundred dollars ($100) or less.),
USE ZONE MAP /
�•l �"`Gli�
,I certify that in the performance of the work.for which this NO:
// +34�//jj Q�� SPECIAL 1
permit is issued, I shall not employ any person in'any manner ADDRESS:4 —9 w �✓/ CONDITIONS O
so as to become subject to the Workers'Compensation Laws: �- r� ' U
CITY "fes le C Q f ZIP 7 i 0
Date .Applicant fie
ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY. Q
NOTICE TO.APPLICANT:'If, after making this ,Certificate of ENGINEER NO. CONST. �NE
Exemption,, you should become. subject Ao the' Workers a. V U
Compensation provisions of the.'Labor Code, you�must'•forth- ADDRESS t ��u ✓' ZTi N
With comply with such provisions or this permit shall beTEL._ STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR �G¢ .�`L� NO: -
L` LICENSED CONTRACTORS DECLARATION i'LIC. CLASS NO._g2G L—DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of-Division 3 of the Business LIC.
and Professions Code,and my license is in full force and.effect. CITY- CLASS BK. PG. % VALIDATION
SQ. ET Q NO. OF / NO. OF. CHECK -
License Number= Lic. Class SIZE o ISTORIES / FAMILIES ONE - r
$V
AL OF WORK O1 (f� W $A
J
:Contractor Date �,. . ADD �.
• • ❑ DATION
NE ..
❑1 am exempt under Sec. ' D
- -ALTER
B.&P.C. for this reasonREPAIR ❑ $
Date: USE OF: -
EXISTING,BLDG. DEMOL ❑` ti ° �I.°:'
Signature APPLICANT. NO. FINAL 2_A2,n
OWNER BUILDER DECLARATION DATE ...ZA ,
I hereby affirm that am exempt from the Contractors License
Law for the following 'reason (Section,7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT BY _ _`}
r I, as owner 'of the property, or- BUILDING my employees with ADDRESS A E
wages as their sole compn ensatiowill do the work and LOCALITY a t ^eC r �' `3�
the structure is not intended or offered for sale(Section
7044; Business and Professions Code.) MOVING k TEL:
❑ I, as owner of the property, am exclusively.contracting CONTR'ACTORti,�
with licensed contractors to constructthe project(Sec- ADDRESS '•=; a •°°t'
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 construction lending agency for FRONT
the performance of the work for-which this permit is issued P.L. t
(Sec. 3097, Civ. C.). SIDE
P.L:
Lender's Name.
, t
P.C. Fee$ Permit Fee ��Z� �✓ LDMA Ref. # �•
Lender's Address ,, D
11 certify that I have read this application and state that the Issuance Fee /3 LDMA P/C#
o
8 above information is correct. I agree to comply'with,all County Investigatio.n'Fee
ordinances and'State laws relatin to building construction, Total Fee 5F �� LDMA•Perm. #
a an hereby authorize ce resent i es of this County to enter
n the above ntio d pr p rty for inspection purposes. y
S- 7-21 . SEE REVERSE,FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent =Date—