HomeMy Public PortalAbout9180 JAYLEE DR_Building_1/14/1985_add fam rm 410 sq ft WORKERS'COMPENSATION DECL•ARATIGN' +
-insurebor a certif cajte of We kersrtC omipensetion Insuron elf
or a certified,copy thereof (Sec 3800, Lab. C:) - - -�
r COUNTY OF LOS ANGELES BUILDIkCa•AND'SAFEYY
Policy No. Company. - -
:Certified,copy is hereby furnished. FOR FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with'the county building"inspec- BUILDING
tion department.' ` ADDRESS
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D'ate_ 'Applicant 1 "CITY C zip p 0 LOCALITY
CERTIFICATE OF EXENO.FROM WORKERS'. N . OF BLDGS - NEAREST • _
• COMPENSATION'INSU RANCE SIZE OF LOT NOW ON LOT CROSS.ST.
(This seciion neednot-be completed-if'the permit is,for one — ASSESSOR
hundred dollars ($100)or less.) : TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL.
MAP 1
OWNER t9 2.!T. O 1( "NO. US�z NE N O
1 certify'thot in the performance of the work for-which.this K�� /
per itis issueclj shall 'not employ any person in any manner -• //- SPECIAL • —^
` -' ADDRESS T "�> CONDITIONS u
so as to become soblecYto the'Workers'Compensation Laws. I
CITY -1 tke. C,T _ L ZIP 17
Date Apphcdnt O
ARCHITECT OR • TEL.-
. NOTICE TO APPLICANT: if, after making this'Certificate of ^' D - - - �'
ISTRICT GROUP _TYPE.. ..FIRE PROC SSED BY "�
ENGINEER,. _ NO. O z
Exemption, you 'should become subject to the Workers' �j !�
Compensation'provisions.of-the Labor'Code,'you.must forth- ADDRESS ./�(y-�
with comply with" such provisions or this,permit shall. be - •-• - -' " _- - -- C
N
TEL
deemed revoked. CONTRACTOR NO. ATISTICAL C N
ST LASSIFICATIO APT COW �
LICENSED CONTRACTORS DECLARATION, . • • , . M -:.-- " CLASS N6.-7-:1' DWELL: UNITS
_ .
1 hereby affirm that I am licensed.under proisions of Chapter 9' ADDRESS NO.
(commencing with Section'7000)of Division 3'8i,the Business and, 2. :._._ LIC- _ _ [=SBEWER MAP
Professions Code, and my license"is in.full force and effect. CITY CLASS. K_ -' PG. VAS N',
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Q NO OF NO OF_ HECK
License Number Lic.Class �� TOR ONE
IES . FAMILIES NE`
LVAILIATIO(h . 1? DESCRIPTION OF WORK', - NEw ❑ O� :o- 1 0 6,..• 3 Contractor Date ADD 0- 2
am exempt under Sec /
:4. t a
' ALTER
B.BP C. for,this reason F T REPAIR ❑ - _. ._
$.. .� r 0 1. 1 4 8 5 �'
Date: USE OF
EXISTING BLDG. L ❑
DEMO
— APPLICANT TEL.
Signature FINAL
OWNER-BUILDER DECLARATION PRINT) • LNO. - •. ,.DAT . -
herebyaffirm-that-1 am exempt from the Contractor's License. `
Law for the following'•reason:(Section 7031.5, Business and ADDRESS FIWAL`
Pr essions Code) m PRESENT
BUILDING
I, as owner of the property or-my employees with ADDRESS _
wages as theirsole compensation,will do the work and
" the structure is not intended or offered for sale(Section. LOCALITY
7044, Business and'Profession's.,Code): MOVING "' ""''' TEL.
I, as owner of the property, am•exclusively contracting CONTRACTOR NO.
❑"' with licensed'contractors to construct the project (Sec-
tion 7044, Business and Professions Code). ADDRESS
_REQUIRED YARD -TOTAL.SETBACK FROM-. -..
"CONSTRUCTION'LENDING-AGENCY SETBACK HWY. PROP. LINE WIDTH
hereby affirm that there is a construction lending agency for. FRONT 1`
-•the-performance-oUthe work for which this permit is issued - " P.L. -_ ,
(Sec'. 3097, Civ. C.). SIDE "
'o P.L.
Lender's Name
o - _- LDMA Ref. # -
.. P.C.Fee-$ - - - - 'Permit-Fee 7LD
Lender's Addressi L.certify that I .have read this application and.state that_the Issuance Fee V L v` MA P/C#
above information is correct. I agree to comply with all County Investigation Fee f
o ordinances and State laws relatin to-building construction,
m 9. 9 _. .. Total Fee---. CDMA Perm. # -
v and hereby authorize representatives of this County to enter •t'
m upon thepbove-mentioned property for inspection purposes.
a ( ///o�f�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ' !
PPlicant or Agent � - Dote -