HomeMy Public PortalAbout9156 JAYLEE DR_Building_12/17/1991_fire dmg repair - L
WORKERS' COMPENSATION DECLARATION
i
I hereby affirm that I have a certificate of consent to self A [PLI � �� O POI , p U��O��G . P E R nn�U
insmor a.certificate of Workers' Compensation Insurance, LI L/11 1J�1 LI L1�11J1/LI
or a certified copy'thereof (Se C..3800,'Lab. C.)
.J�1 COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Policy-Nof_7a 611 Company 517A Fuii,\•' BUILDING' . ,�
❑vCertified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �/5 �i Q
L21. Certified copy is filed with the county building.inspec- BUILDING n
tion department. D
ADDRESS e !� Pmt R. e.b.PL.L
CITY• j.,ti,PL L� C, 1 ZIP LOCALITY
Date / 17 Applicant NO. OF BLDGS. NEAREST
ERTIFI ATE OF EXEMPTION FROM�WORKERS' '. SIZE OF LOT " NOW ON LOT' CROSS ST.'
COMPENSATION INSURANCE j . `, ASSESSOR �5 /
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP,BOOK �c; PAGE �(o'. PARCE�D�
hundred dollars.($100) or less.) +,i. TEL," p
OWNER ���2 :� NO USE ZON _T__OP
I certify that in the,performance of the work for•which thisSPECIAL
�. ✓ �!n
permit is issued, I_shall not employ any person in any manner ADDRESS J%'y /'- /. CONDITIONS a
so a§to become subject to.the Workers:Compensation'Laws. - O
CITY iGvD.Ca C1`T" ZIP
Date Applicant ARCHITECT OR TEL. �
DISTRICT GROUP TYPE FIRE PR ESSED BY
NOTICE,TO APPLICANT:- If; after.making this Certificate of ENGINEER NO. CONST. ZONE C O
Exeni,ption, you should become subject to the Workers' p�Q i U
Com ensation provisions of the Labor Code- ou must forth- ADDRESS .4. LU v a
P- P .. Y. c. :� N
with•comply with such provisions or this permit shall beTEL.
�r '�3 STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR Cr • Ce. NO. b _
LICENSED CONTRACTORS DECLARATION ADDRESS r A .t'6} NO. ! +
CLASS NO. E / DWELL. UNITS
hereby affirm that I am licensed under provisions of Chapter 9 - SEWER MAP
(commencing with.Section.7000)of Division.3 of.the Business �s e,4&5 4 4- CLASS LIC.'
✓ l
and Professions Code,and myCITY t.1 license is in full force and effect. J� BK. PG.- ! VALIDATIOPd
SQ:-FT.: NO. OF NO. OF CHECK
License Number�/ T Lic. Class SIZE STORIES FAMILIES ONE
,. VALUATIOW
Co*ntractoC60 i� s�'u f Cc Date �� .3 DESCRIPTION OF WORK NEW ❑ 7
a S, �000:ob D
ADD - ❑
❑I am exempt under Sec. A^JstlrcGPPC ITRfGirL
ALTER ❑
B.&P.C. for this reason it t5'9 l34>101$4 nC_ QI wA ! REPAIR $
Date: USE OF
EXISTING BLDG. DEMOL
Signature APPLICANT- TEL. FINAL -
OWNER-BUILDER DECLARATION (PRINT). NO. DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS. FINAL- f
Professions Code): PRESENT, _. _ . BY
BUILDING
❑ I, a's'owner of the property, or my employees with ADDRESS
wages as their sale compensation,-will do the work and
the structure'is not intended oraffered for sale(Section LOCALITY _ _
7044,'Business and Professions Code.) MOVING TEL.
I, as owner of the ro erT CONTRACTOR NO. o -• ••=
P p y,;am exclusively contracting d
with licensed controctors•to construct the project (Sec" ADDRESS -� T"
tion 7044, Business•and Professions Code.)
REQUIREDTOTAL SETBACK.FROM -F
EXIST >r"• �. is_.s, .
CONSTRUCTION LENDING AGENCY . • ', SET BACK YARD HWY PROP.'LINE WIDTH
I hereby affirm that there is a construction lending,ogency for" FRONT t i ',•f-
the performance of the-;work for which this'permit is issued P:L. i•'11IN
(Sec. 3097, Civ. C.).' SIDE. .. +-
Lender's Name. t a }i_I I 4
LDMA Ref. #
PC. Fee$.. Permit Fee :W
Lender's Address 36
1 certify that I have read this application and state that the Issuance Fee 955?41 LDMA P/C# D. '
above information is correct. I agree'to comply with all County Investigation Fee
6 ordinances and State laws relating to building construction, Total Fee (19,/ LDMA Perm.
< and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection.purposes.
IfJj�{�,, � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date