HomeMy Public PortalAbout9078ACASO DR_Building (7) ,
WORKERS' COMPENSATION DECLARATION
I have a certificate of consent to sf
insure, or a certif carte of Worke s' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
or a cer ifi d co t ereof (Sec. 38 , lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
t1 r
Policy Company 1 G
BUILDING
Certified copy is hereby furnished. �� FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with'the county building inspec- ADDRESS BUILDING L/-Ir>L -eG
tion department. .yO +�-.
Date Q Applicants= CITY' { ZI LOCALITY
NO. OF B DGS. NEAREST
CER KATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE I PARCEL
hundred dollars ($100) or less.) T
USE ZONE MAP
O
I certify that in the performance of the work for which this . SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS I CONDITIONS O
so as to become subject to the Workers' Compensation Laws. -U
g�yypp n CITY /ZIP Q,
Date Applicant Spm-fiARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
NOT E T APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ' ZONE U
Exemption, you should become subject to the. Workers' I/ w
Compensation provisions of the Labor Code, you must forth- ADDRESS j, ✓ ` v Zt'�s� 0-
with
with comply with such provisions or this permit shall be TELYI" STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
LICENSED . Oro NO 6 17
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the BusinessCITY . , )�. 9a�o7 CLAS �- VALIDATION
and Professions Code,and my license is in full force and effect. a /YBK. PG.
Q SQ. T. ' NO. OF NO. OF CHECK
License Number�,IV.3Q Lic. Class 7 SIZE STORIES FAMILIES ONE
VALUATION
Contracto4T70_4eQa.Tt° Date Z 7 DESCRIPTION OF WORK NEW ❑ E 00
_.—C(JT ADD ❑ Jam' ►
❑1 am exempt under Sec.
ALTER ❑
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
APPLICANT TEL.
AP
Signature (PRINT) � NO. FINAL
OWNER-BUILDER DECLARATION DAT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAb�L T
Professions Code): PRESENT By
ElBUILDING
I, as owner of the property, or my employees with ADDRESS /1
wages as their sole compensation,will do the work and
the structure is notLOCALITY
or offered for sale(Section
7044, Business and Professions Code. MOVING TEL. pp
El1, NO.I, as owner of the property, am exclusively contracting
with licensed,contractors to construct the project (Sec- ADDRESS' 1_l l A-
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST. is t P =.'t �LA=::•4
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT :Ei` a at s
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name C`11!10 <li '
$ �r/ LDMA Ref. # 7L £ a'rC
P.C.Fee Permit Fee (O! , #"'-
aLender's Address �''-"��` �'
0 1 certify that I have read this application and state that the Issuance Fee 7�P LD-MA P/C#
above information is correct. I agree to comply with all County Investigation Fee
$ ordinances and State laws relating to building construction, Total Fee f Co LDMA Perm. #
and hereby authorize representatives of this County to enter
a
upon
theabov mentioned property for inspection purposes.
r�t0 IA " �"'r" SEE REVERSE FOR EXPLANATORY LANGUAGE
�F99 Signature of Applicant or Agent Djdte