HomeMy Public PortalAbout10684 ARROWOOD ST_Building_10/1/1979_add 500 sq ft dining rm, laundry rm, kitchen, pantry, bath (2) WORKERS' COMPENSATION DECLARATION
'reoti bconsent ac,insureor acertifcafe'of Workers' Compensation IurneAPPLICATION. FOR' BUILDING PERMIT
a certkcl copy thereof
(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING ip
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
ADDRESS If All, gy /^fj'y!/�O ' c, r L
tion department.
Date Applicant CITY' �I t ZIP LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE 8 ASSESSOR
(This section need not be completed if the permit is foi one TRACT BLOCK LOT NO. ! MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) TEL.
OWNER Np. USE ZONE MAP
I certify that in the performance of the work.for which this �t ft x /) / SPE
CIAL >_7 r�7
permit is issued, I shall not employ any person in any manner ADDRESS YJAr
ys! SPE
�y4
CONDITIONS a
so as to become subject to the Workers'Compensation Laws. y O
_ CITY ZIP 7,9a U
Date ` Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY Q'
NOTICE TO APPLIC NT: If, after making this Certificate ENGINEER NO. O
Exemption, you should become subject to the Work s' �� �j CONST. ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS e a-
with comply with such-provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. to
deemed revoked. CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3.6f the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT.� NO. OF NO. OF CHECK
License Number Lic. Class SIZE/ STORIES FAMILIES ONE
� VALUATION
�
Contractor Date DESCRIPTION OF WORK • , �!' NEW ❑
1 =
ADD ❑ jJ
Elam exempt under Sec. 6C it pill.
B.&P.C.•for this reason ALTER ❑ `i a
"
�•1 =
Q� $
REPAIR ❑
Dater USE OF
EXISTING BLDG. [ e DEMOL ❑
APPLICANT TEL.' I i Li it
Signature O FINAL
(PRINT) J
OWNER-BUILDER DECLARATION DATE 4- .� ' 1
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS Q FINAL a CHK k. =
r:
Professions Code): PRESENT B �.`, ° =
BUILDING Y t -jri(�S1C
El 1, as owner of the property, or my employees with ADDRESS °
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. g,tiL}`y—:Y`} gi ;' "''_
CONTRACTOR NO.
El 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
ADDRESS
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY .SET BACK YARD HWY PROP. LINE 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 t=: r.t _C:
Lender's Name "
1 C t RDMA•-Ref. # °
P.C. Fee$ � �r0 Permit Fee
Lender's Address
1 certify that I have read this application and state that the Issuance Fee ' AJ?,/C#
8 above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee A Perm. #
a and hereby authorize representatives of this County to enter
upon the abov menti ned prop rty for inspection purposes. "
' e k-•.
6_8—9! SEE REVERSE FOR EXPLANATORY LAN�UA6�
Signature of Applican or Agent Dat—e'' iT 'c41.