HomeMy Public PortalAbout10656 ARROWOOD ST_Building_4/30/1985_Extend living room 'WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT �
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
qo` D 6G1 1)�ItC3ur�.em�� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. ompany P
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS t
Certified copy is filed with the county building inspec- BUILDING
tion7cleepartment ` ADDRESS
Date /� - 5 Applicant d'.. J1-aers C17TY-1701mvVe 044, ZIP LOCALITY y
CERTIFICATE OF EXEMPTION FROM WORKERS`, NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section+need not be completed if the permitr is for one TRACT BLOCK LOT NO. ASSESSOR
hundred dollars ($100)or less-) ((�� `
US Z E P
(,certify that in the performarice of the work for-which this OWNER �" NO: �� O y
permit is issued,'I shall not employ any person in any manner j- 'SPECIAL IL
ADDRESS L CONDITIONS V
so as to become subject to the Workers',Compensation Laws. l
.. � - .•. CITY, - l- � � - _ _ '. . .... _ :_ �
Date ApplicantZIP
ARCHITE TEL.
NOTICE TO APPLICANT: ':If, aftee making this Certificate of ENGINEER O Q���l _DISTRICT GROUP TYPE FIRE �ESSED BY a
Exemption, you should become subject. to the 'Workers' CONST.i/ ZONE u
Compensation provisions of-the Labor Code, you must forth- ADDRESS1 '? L5�0(�' r�r� Y ,� CL
CL
with ,comply•with,.such,provisions or, this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CO O.'` An
An
deemed revoked. CONTRACTOR . l'
LICENSED CONTRACTORS DECLARATION 11 LI CLASS NO. DWELL. UNITS
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS`� r QQ
(c9mmencing with Section 7000)of Division 3 of the Business and _• LIC SEWER MAP
,rofessions.Code,
and my license is in full force"and effect. CITY CLASS 'BK.'.Z. pG '�S VALIDATION
SQ. FT. - n NO.OF NO. OF CHECK .`
License Number Lic.Class SIZE ^ STORIES FAMILIES ONE
a i. i/. a ,, ``•,��,� VALUATION
Contractor Date
DESCRIPTION OF WORK >G X / — NEW ❑
ADD
❑ I am exempt under Sec. , z ALTER 1 9 5. 1 -A
tr
E.BP.C. for this reason I REPAIR..❑ $ '
•# 0 0 0 0 0.1
USE OF
Date: ' DEMOL ❑ 0 1 6 1 3
EXISTING BLDG. -.
Signature APPLICANT _ TEL. FINAL
OWNER-BUILDER DECLARATION PRINT) NO. DATE ,/ 0_0 1 0 6 1 3 L
I hereby affirm.that I am exempt from the Contractor's License
Law for.the following reason".(Section 7031.5, Business and ADDRESS FINAL
Profession's-Code'): " ' ' PRESENT By - - - Q 3 0'_8:5
BUILDING
❑• I, as owner of the property, or my employees with ADDRESS ` Q
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.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed-contractors to construct the project (Sec- . ADDRESS
tion 7044, Business and Professions Code). 3
T.
CONSTRUCTION LENDING AGENCY SET BACKK YARD HWY T07APROP.LINECK FRO WIDTH
I hereby affirm that there is a construction.lending agency for FRONT
the performance of-the work for which this permit is issued P.L. - -
(Sec. 3097, Civ. C.). SIDE
m P.L
Lender's Name t.
o 1/3-1
� LDMA Ref. # .-
m P.C. Fee$ Permit Fee ff t
Lender's Address
certify that I have read this application and state that the Issuance Fee �.��• LDMA P/C# oil,
Q above information is'correct. I agree to comply with all County Investigation Fee / n
m ordinances and State laws relating to building construction, Total Fee16 (� r �• LDMA Perm. #
u and hereby authorize representatives of this County to enter
a upoethn above-me%joned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
^ Signature of Applicant or Agent Date