HomeMy Public PortalAbout9174 JAYLEE DR_Building_6/25/1984_add carport WORKERS'COMPENSATION DECLARATION
I hereby affirm that 1 have a.certificate-:of,consent to.self O D D O D
insure or a certificate of Workers' Compensation Insurance, d 0 CAU DH [ O Q Q D R D Gil C p❑
ora certified copy thereof,(Sect 3800;Lab" C.) at ^r * _ - -
�•, COUNTY OF LOS ANGELES s BUILDIWG AAD Si4FETY'_
Polic0. o. Company
F-1 Certified-copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING �G
ADDRESS
Certified`copy`is filed with the'coonty building inspec- BUILDING' _ , AV
tion department. ADDRESS
S.. ��• e / -
Date ° Applicant r CITY tf Q T ZIP ,i 0 LOCALITY Loo
> NO.:OF BLDGS.. NEAREST _
CERTIFICATE OF EXEMPTION'FROM'WORKERS'
-COMPENSATION INSURANCE' SIZE_ OF LOT 5 % NOW ON LOT CROSS ST.
(This sectionIneed not,be'complete'd if the permit is'for one - I ASSESSOR' - w:
hundred dollars ($100)or less.) �.. TRACT r�4 9 �O - BLOCK LOT NO. MAP'BOOK PAGE PARCELEL
,
OWNER' :1'.Q - NO USE NO
I certify that in the performance of the work for which this U y� }
�j TONE
P ermit is issued, I shall not employ any person in any manner' t SPECIAL- a _ _ _
ADDRESS - A E' . CONDITIONS O
so as to become subject to the rkers'.Compens ',2'Laws. - //.�� y
s CITY - ZIP'7.♦ �__ 99
-
Date Applicant ARCHITECT O TEL.
NOTIC .TO P LIC' NT: If, aft making-this Certificate f DIS RICT .__.GROUP TYPE � FIRE PROCESSED.,BY �.
ENGINEER NO. CONST. ZONE U
Exemption, ou- should beco e'subject -to' the Work s' 5 Ny
Compensation'provisions,of the'Labor Code, you must fo th- ADDRESS Jf e i �r - r - •
with comply .with'.such provisions or this permit shall be
TEL: o ; STATISTICAL CLASSIFICATION. APT. CONDO.
deemed revoked:, CONTRACTOR NO.
_ _.._.
LICENSED CONTRACTORS DECLARATION-:. LIC. -^ CLASS N0: DWELL. UNITS
I hereby-affirm.that I am licensed.under provisions of Chapter 9 ADDRESS NS.
(commencing witk Section'7000)of Division 3 of the Business and _ //•y� SEWER P
Professions Code, and my license is in full force and'effect. CITY D P", BK' VALIDATION
/ ,.CLASS
SQ. FT.. PG
NO. OF NO.OF CHECK
License Number Lic.Class ? t
SIZE STORIES FAMILIES ' ONE �
v k _VALUATIOPI
DESCRIPTION OF WORK'' NEW ❑
Contractor DaTe a ADD ❑ $ „A
I'am exempt under Sec. D
r, ALTEKA R
f3:&P.C. for this reason Z�p $ 4 2.b..A „_
'REPAIR.-
•
r ..
DaTe: USE OF DEMOL ❑ e a 2
EXISTING BLDG. -, t,
Signature' _ APPLICANT a TEL.
' :_.
OWNER-BUILDER DECLARATION DATE r77/
I'hereby affirm-that l am exempt from the Controctor:s,License i z
Law for the following re6sori (Section 7031.5, Business and ADDRESS / 1 FIN o o 2-�J 7 7 c� I
`Pro essions'Cocle): PRESENT _1 By D 2 2�—•8 4
BUILDING �r T
1,, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code) "" MOVING "'"" TEL. •' - -' ' - D "' - `
1, as owner of The property, am exclusively contracting CONTRACTOR NO. - - 2 2-x,`3 A E`
with licensed contractors:'to construct the project (Sec- ADDRESS t
tion 7044, Business and Professions Code). # o o o o 2 3 -.
REQUIRED .. TOTAL SETBACK FRO XIST..: _. _ ! i
CONSTRUCTION LENDING AGENCY SET BACK YARD'" HWY - PROP. LINE WIDTH
I herebyaffirm that there is a construction lending agency for ot;o
9 9 Y FRONT
-the performance of,the-work for which this permit is issued P.L. Q o o �.J 1i
(Sec. 3097, Civ. C.). SIDE
n
P.L. _ r ,
Lender's Name _ 2 5—8`U
0
--- e 77
��7,� LDMA Ref. #
P.C.P:C. Fee$-- - -Permit fee o •ice #.
Lender's Address f�R,.b - p. 0 0
1.1-certify that-L_have-read this application and state that the f Issuance Fee - LDMA R/C•# N Crl •cN o `Iv
a above information is correct. I agree'to comply with all County Investigation Fee CTt o fV '
ordinances and_State jaws relating to_bu.ilding construction, _ .... TC Fe Z LDMA Perm. #- - _ice -d
U and hereby authorize representatives of this County to'enter 0 CD CD o
m upon the above-mentioned property for inspection purposes. Q _,CD
CH '
L 2,.'
Signature of Applican or Agent - ate - -- --- W ._ �__ _-_. _. _ _