HomeMy Public PortalAbout9023 JAYLEE DR_Building_7/1/1986_reroof WORKERS'COMPENSATION DECLARATIONt
I hereby affirm that.I,have a certificate of consent to self O
osure, or a certificate of Workers' Compensation Insurance, Q .. Oo G3 C3 M:O d DD G1 C�' p C QG O
or 6'-,certified'copy;thereof{Sec. 3800 Lab:C.) COUNTY OF LOS ANGELES BUILDING.ARCD S4FETY
Poltcy rvo. • •.r. .r mpany Fremont.- l ndemn i ty
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS Q
® Certifi'ed copy.is filed wiTH•the'county building inspec- BUILDING t
`.ttiion.departrrent. ADDRESS _ 02 E Jay1 ee
Date••6 23C86 - Appliccint.V 1 C9'.1 n ROOF CO o CITY Tem C 1 t ZIP - LOCALITYAAAA
_.
CERTIFICATE OF EXEMPTION FROM WORKERS' "' ' - -NO.OF BLDGS, NEAREST.,:,.,.: ,. . .
COMPENSATION-INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. .:
(This section'iieed.not abe completed-,if the•permitls' for one - - -
' 'ASSESSOR -
hundred dollars ($100)or.less.):
TRACT BLOCK LOT NO, MAP BOOK PAGE: PARCEL
n+ - _ USE NE. MAP
TEL.
I ertify that in,the performance of the work•for which this OWNER NO. O r
0.
permit'is issued, l shall-`not employ any person in any manner - SPECIAL - �;
so,as to become subject to the Workers'Compensati'ori'Laws. ADDRESS CONDITIONS V
CITY ZIP_.
Date Applicant.'
'NOTICE'TO-APPLICANT`,'If after'making`this 'Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE _ FIRE _ PRO SSED BY
ENGINEER NO.
Exemption you should become;subject to the Workers' O t
Com ensotion rovisions,of the Labor Code, •ou.must forth- ! 0.
C NST/ ZONE
P. . P Y ADDRESS : .. (I _. ..with comply ,with' 'such provisions'or.this permit shall be •• - -
TEL. STATISTICAL CLASSIFICATION: APT. NDO. ''•
deemed_ revoked. CONTRACTOR —r NO,
1
LICENSED CONTRACTORS DECLARATION - LIC. CLASS NO. —DWELL. UNITS
—
I hereby affirm,that.I am licensed underprovisionsof Chapter 9 ' ADDRESS :P a00. Box J NO. 606 0
(commencing with Section 7000)of Division 3 of The Business and _- LIC.
•SEWER MAP
Professions Code,.and myalicense is in full force and'effect. CITY CLASS 1 BK. PG. " 'VALIDATION'
SQ. FT, NO.OF NO. OF CHECK
LicenseNumb'er a'6o650'' Leas' C39"' _ SIZE STORIES FAMILIES _ ONE 11
t ❑ VALUATION _
Contractor Dare W '
DESCRIPTION-0 WORK - NEW
❑,I am exem -t under Sec t,r ��- _
ADD ❑ a_ D
P
-. ., ALTER
,B.BP.C~for this reason L rock REPAIR-..Q S
USE OF
-Date: EXISTING BLDG. Dwelling DEMOL ❑ "
_ . _ :_.,-_ .. X4939
`Signature "" APPLICANT TEL FINAL
OWNER-BUILDER-DECLARATION. PRINT) � Cn NO. DATE - ��• -•-
hereby-affirm that I-am exempt from the Contractor's License 0 0 0 0 0
Law for the followinglreason;(Section 7031.5, Business and ADDRESS $ b C FI '
Professions Code). PRESENT _ _-. --.- o>.0 5
BUILDING +
2
I, ds owner of the property, or m ' employees with ADDRESS -- _,
9.�..
wages as their sale compensation,will do the work and
.the structure is not intended or offered for sale(Section LOCALITY
7044, BLsiness and Professions Code): ` ' •' ' •'' '. ' MOVING '-TEL.•'-
Q71 _ 86
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- .-
tion 7044, Business and Professions Code). ADDRESS l
-:, REQUIRED TOTAL SETBACK FROM_ . IST.-
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. - — -
(Sec. 3097, Civ. C.). SIDE
- _
P.L. . _ - f:
Lender's Name
o .. LDMA Ref.
m Lender's Address P.C. Fee$ Permit FeeS48,7137 _.
j _ _ -
' I.certify_that-I have read this application and state that the _ _ _ _-_ Issuance Fee < 7LDMA P/C# --- - ''
a above information is correct. I agree to comply with all County Investigation Fee '
m ordinaneces and State laws relating to building construction, _•_ •Total Fee - TDMA Perm.
u and hereby.authorizrepresentatives of this County to enter
upon t e above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
- Signature of Applicant or Agent.. Date