HomeMy Public PortalAbout9194 JAYLEE DR_Building_2/6/1989_reconnect fam rm to garage WORKERS' COMPENSATION DECLARATION
titficate of consent lf. D,
o DD 0[ l p C 13
I.
t �� Udrtsreoracertifiateof Workers' Compensation nsuraneCAUO
or a cerh*:ed copy thereof �� ..,.
(Sec. 3800,,Lab C.)
Policy Certified co s here6 pfu.y.
COUNTY OF LOS:;ANGIEL'ES . BUILDING AND SAFETY
furnished. '` BUILDING C``
Py y FOR APPLICANT-TO FILL IN: ADDRESS.
i in . . ,
ifi is filed with the count building s ec=
Certified copy. y 9 P BUILDING. )
tion department. .ADDRESS' .1 `I' b- ;.T...,,. •• /C!,
Date Applicant CITY Ce ZIP i'�8 U LOCALITY,.- 1
CERTIFICATE OF EXEMPTION FROM WORKERS NO. OF BiDGs. / NEAREST
COMPENSATION INSURANCE SIZE LOT YU 1 u` CROSS ST
SI OF �(/� NOW ON 10T
(This section need not be completed if the permit is for`one ST A»T7t1•%tr1l' ,$71," r /p0 ASSESSOR s
n D
hundred dollars ($100) or less.) TRAOf, BLOCK LOT NC�o •`Za9 ._'MAP BOOK,,, PAGE',' PARCEL
1 certify that in the performance of,the work.for,which this . OWNER �7U,
NL U MAP
ADDRESS
permit is issued,,)shall notemploy.:any pers in,any manner USE
ZONE
• SPECIAL /f
g� !�. �� CONDITIO /
so as to becomesubject to the W s" dmpensat on Laws. /' jJ
Z``' } s' - y �s CITY �..ts' ZIP �C7
Date / /� APPlicant �`� ° Pl..,.
NOTICE TO i APPLIC 4NT:,.If, after maki this_ Cerhfi ate of ARCHITECT OR TELI I .. 'DISTRICT,,: GROUP TYPE FIRE PROCESSED BY
Exemption,-you "should become subject to the';Workers ENGINEER " NO. ,
p P
y ADDRESS �1�g
4� CONS NE r
Comper rovisions of the Labor Code„ ou must forth ° ;'�
with comply-with such provisions or flits permit,'sholl be TEL. STATISTICAL.CLASSIFICATION, AP.T. CONDO. .
deemed revoked :; a,
CONTRACTOR' NO. tS
LICENSED CONTRACTORS`DECLARATION'
LIC. CLASS;.NO D,WELI. UNITS
I hereby,affirm that 1 6m,'licensed"underprovi`sions of Chapter 9 "` ADDRESS. :" NO:.
(commencing with Section 7000)of Division 3 of the Business and LIC . - SEWER MAP -
Professions Code and my license is in full,force'ondeffect. CITY CLASS VALIDATION }
0
SQ. FT NO; OF NO.,OF CHECK
License Number Lic.Class SIZE �'�GQ STORIES I FAMILIES ONE' .. . d
u BK PG
i15
Contractor - Date " DESCRIPTION OF.WORK ��A7°� 7 NEW
ADD C)
❑
VALUATION
7 _rVt/U E� vt
1 am exempt under Sec 1
ALTER
B.&P C for this reason �Y�' f` Q r� $ �'`
REPAIR
r 'Date. .,USE F -. DEMOL Z
EXISTING BLDG..... a
Signature FINAL A
APPLICANT. : TEL.
�, 3
G
OWNER-BUILDER DECLARATION -• (PRINT) NO. DATE — '
Lhereby affirm that 1,6ri)exempt from the Contractor's License
`Law for the following reason (Section 70311,5; IN,Business and ADDRESS
FINAL Ni"
r
Profen ' Code) PRESENT BY a •i:�
BUILDING '`•
rP�11, as owner.,ofthe property, or my, employees with ADDRESS ' ' " •
wages as their sole compensation;,'will.do'the work and, 5. -
the structure is not ntended 6�'offe ed
044, Business and)Profess ons Code) for sale Section LOCA.ITY
MOVING TE a C
`CONTRACTORNO2
I; os.owner of the property,.am exclusively con0cicting
with licensed contractors to construct the project(Sec-
tiADDRESS c t a 3
on 7044, Business and Prof essions'.Code). > _
REQUIRED TOTAL SETBACK 4 °,
CONSTRUCTION LENDING AGENCY- SET.BACK YARD HWY PROP:LINE WIDTH r t "fill .
I hereby affirm that there is a construction lending agency for FRONT r
the performance of the work for which this.permit is issued P.L. }:. -
(Sec. 3097, Civ. C.)- SIDE F it it tt"1_i- t 1
Lender's NameILDMA Ref.
.
Lender's Address P.C. Fee$' Permit Fee
o I certify that I have read this application and state that'the Issuonce Fee -d� _ 7LD P/'C#
above information is correct. I,agree to comply with.all County InvestigahonFee"
0 ordinances and State'laws relating to building construction, • Total Fee TT o LDMAPerm..#, .
R and eby autho" a representatives of this'County to enter"
m on th abov en,.oned `property for ' spection purposes.
Z 6 �5 -SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign of Applicant or Ag Dote