HomeMy Public PortalAbout5551 PARMERTON AVE_Building_11/18/1992_add on to bath and bedrm #2, 84 sq ft WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a 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.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po❑liay No. Company _
eUUDING C 1
entified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDREss 5 JS 1 rfr
Certified copy is filed with the county building inspec- ADDRESS TIC,e /I
tion department. ((//\��J,,\\►�``A} ADDRESS INCL /V
Date 0 _16�L Applicant `J"� _ CITY Z- <- NO OFZeLDGS. I LOCALITY f f
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST
CROSS ST. L.
COMPENSATION INSURANCEASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL O
hundred dollars ($100) or less.) L TEL,
OWNER .:Ct. ��\ NO.- USE ZONE MAP
11140.
I certify that in the performance of the work for which thisSSS1 r1 _ SPECIAL }
permit is issued, I shall not employ any person in any manner ADDRESS J T�L"s CONDITIONS O
so as to become subject to the Workeri Compensation Laws. `r �r 1�c' U
CITY ZIP
Dote Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY W
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER L� (�,, NO. — Z�: {�' le CONST. Z E V
Exemption, you should become subject to the Workers' ADDRESS ; 1, _ 1kk`��s^'KL"^C'w J' Q� W
Compensation provisions of the Labor Code, you must forth- .� L �
with comply with such provisions or this permit shall be (s'y�� ((�� � TEL 1/ �� STATISTICAL GLA$SIFICATIQN APT. CONDO. Z
deemed revoked. CONTRACTOR {-� �A.'•^�i N0.4` Z� I /� /
LICENSED CONTRACTORS DECLARATION LIC CUSS NO. DWELL UNITS
—
I •"
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS w%k wo^cNO. 4-410 ` SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC' D
and Professions Code,and my license is in full force and effect. CITY T•L. CLASS IeT'1 6z VALIDATION
(,] SQ. FT. NO. OF NO. OF CHECK
License Number TkIall Lic. Class,_ S¢E STORIES ' FAMILIES 1 ONE
EF,��_ + �f VALUATION
Contractor • , �9 Date `��— `� DESCRIPTION OF WORK �L� NEW ❑ $ O
❑I am exempt under Sec. Y^""` Poo.
ALTER ❑
B.&P.C. for this reason REPAIR ❑ $
Date: USE OF
EXISTING BLDG DEMOL ❑
tit APPLICANT TEL.
S'gnat re (PRINT) NO. �,— �„ FINAL
OWNER-BUILDER DECLARATION `' DATEt1_6
I hereby affirm that I am exempt from the Contractor's License ADDRESS 1 1 �f s'a'�s^^c FINAL «;
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT BY
❑ I, as owner of the property, or my employees with BUILDING
wages their sole compensation,will othaworkand ADDRESS
, 3eN3
,0
l,7
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y ,]
the structure isnot intendedor offered for sole(Section LOCALITY j
7044, Business and Professions Code.) MOVING TEL 1
' ❑ I, as owner of the property, CONTRACTOR NO
p p try,am exclusively contracting aT
with licensed contractors to construct the project (Sec- ADDRESS ACC l.r
tion 7044, Business and Professions Code.) - -
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST JOUy
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT 2 ITEM]
the performonce of the work for which this permit is issued P,I.
(Sec. 3097, Civ, C.). SIDE TOTAL 287 . 44
CHECK Lender's Name Y s +��.?Y
,y q LDMA Ref. R
P.C. Fee$ �d Permit Fee /� f: l'IIjE .I�Q
Lender's Address
a I certify that I have read this application and state that the Issuance Fee 7S LDMA PVC N
pool
' above information is correct. I agree to comply with all County Fee /y�r'.( p
ordinances and State lows relating to building construction, Tool Fee LDMA Parm. M OOOO-10101 11]Lv/9-
a and hereby authorize representatives of this County to enter 2 �,c-
gY¢ 6.5b� API
upeR'1he above-rpen 'oned property for inspection purposes.
�✓n9'),��7,po`.�I-�1' � 1b 1..� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote