HomeMy Public PortalAbout9194 JAYLEE DR_Building_2/6/1989_windows + WORKERS' COMPENSATION DECLARATIONtci se
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nsureboraafcertifcale`of Worker' Com�eensaton5ensuran elf ���'� O F'�• O D ' LDR V� '��•�fJV.U��
hove 6 C�Q�OQ O
or a certified opy',thereof(Sec.,3800,;Lab:C.)
C00NT-Y OF'LOS /ANGELES BUILDING AND'SAFETY .
Policy No Company
BUILDING
Certified'copy ''hereby furnished:' FOR:APPLICQNT'TO'FILL IN �.�
Certified copy is filed:with?the county building inspec' BUILDING
❑ .tionr de ailment. :ADDRESS ' ADDRESS
C� "'
d'4
Pate. an :. CIT.y , - ZIP I�'7Y� . . -
` LOCALITY
CERTIF,ICATE OF EXEMPTION FROM WORKERS' NO.OF BLD S. NEAREST
COMPENSATION INSURANCE "' SIZE OF LOT NOW ON LOT. CROSSSST. ,. f�f .ltiZ a!
y
ASSESSOR,,
(This section need not be completed-if the permiT-is for one ` TRACT "' BLOCK LOT NO.•: - '
hundred dolafS ($100):or less-)'.;- MAP BOO
- r i /
MAP
PAGE PARCEL
'I certify that in the-�performance of the work for'which.this
permits issued, I,shall:not empIoy,an,y,person in any manner
NO. •
_..J SPECIAL
so,<'os to become subject+to'the.,Workers'.Compensation_Laws. -ADDRESS rJ �'�l�„ � - �` CONDITIONS
Date Applicant r�A ^���j ZIP
CITY y1�7 G "7�0 °
NOTICE.TO APPLICANT ,',If after makin this Certificate, of ARCHITECT OR TEL
9 ENGINEER NO.
Exemption, you, should-'become subject to .the Workers DISTRI
e
CT GROUP TYPE FIRE --PRO SSED BY
/� •CONST ZONE
Compensation pr, cions of the Labor Code,you,must'forth- ADDRESS
with comply with such provisions or.this permit shall be: „
deemed revoked TEL CAL CLASSIFICATION
LASSIFtKATION APT;'' CONDO.
CONTRACTOR- • NO.1
LICENSED CONTRACTORS DECLARATION uC. CLASS.NO. DWELL.'UNITS
I hereby affirm that Lam licensed under provisions of Chapter9 ADDRESS NO: SEWER MAP
(commencing withiSection'7000)of Division of the,Busmess and t ` LIC.' f
Professions Code, and my licPf
ense.is m ful1.force--and effect"' CITY _ CLASS BK VALIDATION y
License Number Lic SO:'F7. NO.•OF NO.OF, CHECK
Class SIZE STORIES FAMILIES +J ONE •
' „ NEW VA RI U
DESCRIPTION`OF.WORK ��9J
Contractor Date
Q'
O I'am exempt under-Sec:. Gr4s�WtiY1(�!r`v.•.. . _(.1�j u.CcCx. /�
ADD ❑ S' V ODr
ALTER. .❑ - ;
'B.BP.C. for This reason G ddL�-j ^ 4. ”. LV r;�J $" p
PAIR .❑
Date. ' USE OF 'DEMOL r.
EXISTING BLDG.. .' ._ ❑ .. Y _
Signature FINAL
APPLICANT TEL
OWNER-BUILDER DECLARATION PRINT)' NO ' DATE�j
I hereby affirm that I am exempt from the Contractor's License -
ADDRESS
Law for the followin reason- Section 7931.5, Business andFINN
,� •
•
Profe stons Code PRE ENT B
- �j''� BUILDING
LTJ 1, as owner of'the 'property,,,or, my,employees`with ADDRESS
wages as their sole,compe`,nsation,•will:do the work,aeid -'es z _
the structure is not intended or offered for sale(Section LOCALITY '!
7044, Business and Professions Code) MOVING' TEL
:..` a .. CONTRACTOR .'NO.
1;as'bw,ner of the property; am exclusively contracting '
with licensed'contractors.to construct the project'(Sec ADDRESS 1 (y
`tion 7044, Business and Professions Code). Y r3 t7
:..
3 6
REQUIRED TOTAL SETBACK F r
CONSTRUCTIONAENDING AGENCY 'SET BACK YARD HWY PROP. LINE WIDTH
.1 hereby affirm that•there is a construction lending agency for FRONT
the performance of the work'for which this permit is issued P1.
(Sec.3097,'Civ.'C..) p SIDE ✓i r JI
f: -
Lender's Name
� LDMA Ref. #
P:C. Fee$ Permit fee
Lender's Address
o I certify that I have read this;application and state that the Issuance'Fee Q r\ O LDMA P/C# `
o above information is correct. I'agree to comply-with all County Iinvestigatjon Fee
0 ordinances and State laws relating to building construction, n
0 �
and hereby authorize'representatives-of this County to enter Total Fee. LDMA Perm. #
u/p'o�n.t e ove=me boned property for inspection purposes
SEE`REVERSE FOR EXPLANATORY LANGUAGE
Signator of Applicant or A6dgi /Date