HomeMy Public PortalAbout10714 ARROWOOD ST_Building_3/8/1989_add den extend bedroom, bath, fireplace ',WORKERS' COMPENSATION DECLARATION
' affirm that I have a certificate ent to self
sure --,ra ceTcte of Workes' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
�etficoraied y
thereof (Sec. 3800, Lab. C.), COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poli ty No. Company
BUILDING
❑.' Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS [ L 1 —L �"12 YZC cu o It
r ❑, Certified copy is filed with the county building inspec- BUILDING i{ In.n /�
tion department.. ADDRESS 10' -tom� r` r{'V W
Dae Applicant CITY L L� Li "` ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE_OF LOT 0 U NOW ON LOTS NEAREST r—
CROSS ST. G' L• 'I C1 N• r
COMPENSATION INSURANCE '' ASSESSOR
(This section need not be completed if the permit is for one TRACT' t8 ICS BLOCK LOT NO. MAP BOOK PAGE I PARCEL
hundred dollars-($100) or less.) `n TEL
OWNER K 1 Y S ! �I ,)- USE ZONE OP / -7
I certify.that in the performance of the work for which this `r,1 "1 ! `O�� sr�n� ,�1 t SPECIAL /
permit is issued, I shall not employ any person in any manner - ADDRESS V / )`dL C� �(�K� v 1J / CONDITIONS CL
O
so as to eco b subject to the Wo rs' Compensatiohd Laws. .�
` CITY G- ��T. ZIP_. U
Dot Applicant 1 ARCHITECT OR TEL.
NO CV TO APPLICANT: If, after making this Certificate of ENGINEER NO.. DISTRICT GROUP.TYPE FIRE CESSED BY
CONST ZONE O
Exemption, you. should become subject to the Workers' /,(� V U
Compensation provisions of the Labor Code, �'3 / w
p. p you must forth- ADDRESS
a
with comply with such provisions or this permit shall be i TEL r STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR CP ( NO '13'-t 3�Cs 3
LICENSED CONTRACTORS DECLARATION. �}, UC. ��7� ^ _ CLASS NO. DWELL. UNITS
I hereby affirm that l am licensed under provisions of Chapter 9 ADDRESS V !7 ( C✓P1NO �Y
(commencing with Section 7000)of Division 3 of the Business y. LIC. SEWER MAP
CITY ( / ��� CLASS I
and Professions Code,and my license is in full,force and effect. BK._J pG 6 VALIDATION
7 SQ. FT tic. NO. OF ( NO. OF CHECK
License Number -� � Lic..Class� SIZE1t�J STORIES [ FAMILIES ONE
//�c� / A 1 �V VALUATION
ContractoO Li `V /fir _; `06 Date l / DESCRIPTION OF WORK (_(v NEW ❑ $
I am exempt under Sec. ' L— � l� ADD OC CJ
B.&P.C. for this reason �-- f'� ._. (J�. ��-ALTER ❑
REPAIR ❑ $
USE OF -
Date: EXISTING BLDG,_- ICV L- • icor c QIV DE OL ❑
h> Signature APPLICANTTEL. r
OWNER-BUILDER.DECLARATION (PRINT).(5) L j/V �j�Sd[�(' NOk "i jj^j. FINAL
I hereby affirm that I am exempt from the.Contractor's License ADDRE59W f/ �� Rx+rJ ��'�.p (, }"
DATE
Law for the following reason(Section 7031.5, Business and FINAL
Professions Code): PRESENT B
BUILDING Y r
❑ I, 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. s
ElI, as owner of the-property, am exclusively contracting CONTRACTOR NO.
411
" _5 -•1a5
with licensed contractors to construct the project (Sec- ADDRESS a " Nt
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 FRONTy (
the performance of the work for which this permit is issued P.L. - l
(Sec. 3097, Civ. C.). SIDE
P.L.
7.1 :. Y
Lender's Name n `.\
LDMA Ref # ,
P.C. Fee$ Permii Fee Lender's Address
a I certify that I have read this application and state that the Issuance Fee �• v — LDMA O/C#
8 above information is correct. I agree to comply with all County Irivestigation Fee s
R ordinances and State laws r lating To-building construction, Total Fee �� LDMA Perm. #
a and here y authorize repre ntatives of this County to enter
Cp t ab@ve en—boned operty for_inspecti fi pu.poses. r/
7 J r SEE REVERSE FOR EXPLANATORY LANGUAGE J
Signature of Applicant or Agent ate