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HomeMy Public PortalAbout9157 JAYLEE DR_Building_6/11/1991_reroof WORKERS'COMPENSATION DECLARATION in urebor afcertificatefirm thatlof Workers'Compenshave a certificateotionoln uranoce, olr L/-1� L CA LI �®U M V F O� O U��D��G P E�LI V U�U �.a jertified copy thereof (Sec. 3800, Lab. C..)g COUNTY OF LOS ANGELESBUILDIi1G SAFETY �J O Policy No. Company SPM F��� . Certified copy is hereby.furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS aCertified copy is filed with the county building inspec-- BUILDING _ tion deportment. N �_ ADDRESS /g T VL CE -f p� LOCALITY Date CO—�I`7 Applicant. ff L ���F7�{� CITY ` `/w L' ZIP /I/ O v CROSS NEARESTT. Pp CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. 3 y. TEL. / _ �/ SPECIAL CL I certify that in the performance of the work for which this OWNER v t g NO CONDITIONS O permit is issued, I,shall not employ any person in any manner _ DISTRICT GROUP TYPE FIRE PR ESSED BY C1 so.as to become subject to the Workers'Compensation Laws. ADDRESS 5 L��7 ,0� ` n CONST-. / ZOyE . .iJS v �•/•{ CITY �/y .109 �' ZIP J 7� f Date Applicant STATISTICAL CLASSIFICATION APT: CONDO. U 'NOTICE TO''APPLICANT: If, after makingthis Certificate of ARCHITECT OR TEL. W ENGINEER NO. CLASS NO. DWELL. UNITS CL Exemption, you should become'subject to the Workers' tit Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this.permit shall be ;deemed revoked: ` TEL. ��CC• BK./��PG, VALIDATION CONTRACTOR SAF/ l% NO. �J'�J /��' LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS /y VALUATION (commencing with Section 7000)of Division 3 of the Business and - kA— n LIC. Professions Code, and my license is in full force and effect. CITY C /C CLASS $ ��• SQ. FT. NO. OF j NO. OF CHECK (License Number � �74 Lic.Class `� ✓ SIZE ' STORIES ` FAMILIES ONE CaniractorASiC�oOF/�Jt7 DFP $ate 915-3 DESCRIPTIONOFWORK Q-� �/ NEW $ P 9 9 CVX Y vlvoo i gr•RJ9 ADD I am exempt from the licensing requirements as I am a L licensed architect or a registered professional engineer n . ALTER Q ,FINAL C^ acting 'in my, professional capacity. (Section 7051, �./I,�. QJ���SA/�CGl1 REPAIR DATE Business and Professions Code). USE OF FINAL v EXISTING BLDG, DEMOL By.. Lic:or Reg'No. _Date 'APPLICANT TEL. l OWNER-BUILDER DECLARATION (PRINT) NO. � � I hereby affirm that I am exempt from the Contracto'r's License 1 Law for.the following reason (Section 7031.5, Business and IADDRESS Professions Code):: • PRESENT :❑ BUILDING I, as-owner of the property, or my employees with ADDRESSE:a. wages as their sole compensation,will do the work and the structure isnot intended or offered for sale(Section LOCALITY ; E __a 11-IJ 7044, Business and Professions Code). MOVING TEL. ."I, as owner of the property, am exclusively contracting CONTRACTOR NO. s t L(1L- ; with licensed contractors to.construct.the project (Sec- ADDRESS a: tion 7044,-Business and Professions Code). t I HL_ c-t •- m -+ REQUIRED` TOTAL SETBACK FROM EXIST. ;i:r :-t-; CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINE WIDTH _.}['_.;:, t t•==r_, I hereby'affirm'that there is a construction leriding agency for FRONT the performance.of the work for which this permit is issued P.L. i;P ;y G z f (Sec. 3097,Civ. C.). SIDE P.L. Lender's Name, /4 mP.C. Fee$ Permit Fee Lender's.Address 5 1 certify that I have read this application and state that the Issuance Fee above information.is.correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, pf7 Total Fee , and hereby authorize representatives of this County to enter U upon the bo e tinned property for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE .SigtureJ&A_!Ilpligont or Agent Dote -- ©s