HomeMy Public PortalAbout9662 CRAIGLEE ST_Building_11/30/1989_patio and deck (2) WORKERS' COMPENSATION
�r DECLARATION-
MbLLD)
consent self
�� M 0�. p � 3 �*4 ' Workers' Compensation Insurance,ce .:
Aor a certified copy thereof.(Sec. 3800,'Lab. C.) ,
i COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING r
❑ .,Certified copy is hereby furnished. FOR APPLICANT TO FILL IN - ADDRESS. ���
'
El " Certified copy:is filed with the county building inspec- BUILDING /� ►� - -�
ADDRESS .•
IOvAl LZ4— . -7
tiJon•department. 'y-
Date � Applicdnt'� '�T,""' �f OF BLDGS!
CITY' t//' 1 T NO LOCALITY
NEAREST
CE�OF EXEMPTION-FROM-WORKERS' SIZE'OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not-lie completed.if thepermit is for one TRACT BLOCK 116T NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) r TEL.��/!
I certify,that in the performance of the work for which this J NO.
PECIAL
permit Xs issued, I shall not employ any person in.any manner ADDRES hi6_ 1 CONDITIONS CL
soas to-become subject to.the Workers' Compensation.Laws. [ S O
CITY .Qom. �( i� ZIP /. U
:Date Applicant" ° ARCHITECT O TEL. 0
' DISTRICT _, GROUP TYPE FIRE. PROCESSED BY- 0
COTICE.TO APPLICANT: If, making,this"Certificate of - ENGINEER NO.. ST�7� E f—
N CON .
Exemption, you:should become: subject to.the. Workers' w
Compensation.provisions of the Labor Code,,you.must.fo`rth- ADDRESS ✓ `! ^`
N
with comply with such provisions,or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed'revoked.' CONTRACTOR NO. _
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.- 'DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS. NO.
LK: SEWER MAP
,(commencing with Secti6n.7000)of Division 3 of the Business ,•
and Professions Code,and my license is in'full forceeffect, CITY: CLASS BK 1✓PG- VALIDATION
SQ FT." NO. OF NO. OF CHECK'
License.Number Lic. Class SIZE STORIES FAMILIES ONE, I,
VALUATION d v
Contractor Dgte DESCRIPTION OF WORK NEW
50 O
ADD ❑ S. :
I am exempt under Sec
ALTER ❑ D
B.&P.C. for this reason" REPAIR ❑ $
Date:' USE OF
EXISTING BLDG. DEMOL El
Signature APPLICANT, TEL. FINAL
OWNER-BUILDER DECLARATION. (PRINT). NO. DATE
I hereby affirm that I am exempt from the Contractors License
Law for the following reason-(Section 7031.5, Business and ADDRESS FINA(�
y.
Professions Code): PRESENT. - _ By,
BUILDING r `;... ; �... tY,.g.
❑ I; as owner of the property, or my employeeswithADDRESS
vJages,astheir sole compensation,will do the work and _!'t j
;9.• c
the structure isnot intended.oroffered for sale(Section. LOCALITY ��=`
7044, Business and Professions Code:) MOVING, TEL. 1, I�
•' CONTRACTOR NO. '
MS
I, as owner of the property,,am exclusively contracting
a= a.
with licensed contractors to construct the project (Sec- . 's; _a� =a
ADDRESS'
tion 7044, Business and Professions Code.) C, =
REQUIRED TOTAL SETBACK FROM EXIST: CHECK
��a�=
CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINE WIDTH'
I hereby affirm that there is a construction lending agency for FRONT CHANCE 00
E
"the performance of the work for which,this permit is issued P.L.
(Sec..3097, Civ.•C.)..: SIDE,
II'i�O I 1'-
Lender s Namer -�-t �. �.El,a /8:
LDMA Ref. #
Lender's Address P.C. Fee$ Permit Fee 7158 11 �!(°I,L°��
n �:
- I certify that I have read this application and state that the Issuance Fee i 'O LDMA P%C# D
above•information•is correct.`I agree.to comply with all County Investigation Fee
8 ordinances and State-laws relating.to building construction, Total Fee LDMA Perm. #
< and hereby authorize representatives of this County to enter
upon thabove-menti ed'prerty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of Applicant or gen Date