HomeMy Public PortalAbout5539 PARMERTON AVE_Building_8/6/1992_remove existing rm and replace with patio jWORKER� COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self �#
insure' or a certificate of Workers' Compensation Insurance _ APPLICATION
L I CAT I O N .FOR BUILDING. PERMIT
i or certified copy thereof (Sec,3800,,Lab C ) i •, _ "_ - . COUNTY OF LOS ANGELES yr BUILDING.AND SAFETY
• 0
i Policy No Company '-'- ' -
- _ _ BUILDING 'Certified copy is hereby furnished n� � FOR APPLICANT TO FILL-IN � ADDRESS
❑ Certified copy is fdediwnh the county building inspec- BUILDING A.V H/ - -• - -i"` �'�' " '
• +tion department . - w i ADDRESS J J
��s
Date�' Applicant _ (ITV R ZIP LOCALITY t- _
• CERTIFICATE OF EXEMPTION•FROM WORKERS SIZE OF LOT '" NO ONLLOT -'- NEAREST - _
CROSS ST
COMPENSATION INSURANCE," ' "` - _ .ASSESSOR .fit, -t
,JhiS section need not be completed if the permit is for one TRACT i" ' BL • �"' " LOT NO - MAP 13001( (/ T y PAGE 0 PARCEL 00 -
t hundred dollars SIOD) or less ) ' ' TEL
SPECIAL - , - n}.
, permit is issued, Irshalmot employ any parson in any manner ADDRESS � - Q• -- - CONDITIONS .^' � '
so as to become subject to the Workers'Compensation Lawst + - • '' /I - O
,, . .T i - • . CITY .ccs,,.......ZIP (. "1 ,__ ...- - r -` t -• "T - U
Date - Apphcant • ARCHITECT OR TEL DISTRICT _ GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT„If after making this Certificate of ENGINEER 3 _ _ NO _ _ - CONST f ` ZONE
Exemption you should become subject to the Workers' - + r �0�
' Compensation provisions of,the,Labor Code you must forth , ADDRESS
with comply,with such provisions,or this,permit,shall be • TEL STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked „ i CONTRACTOR NO -. - QZ/ d i' -
K
LICENSED,CONTRACTORS DECLARATION .-.. ADDRESS LIC
CLASS NO DWELL UNIis i
�I hNO
ereby by,
ifiat I am licensed under provisions of Chapter 9 _ _- __ - SEWER MAP
' (commencing with Section 7000)of Division 3 of,the Business ' -' LIC '
and Professions Code,and my license ism full force and effect CITY - CLASS BK PG ' VALIDATION
T '- - SO FT ' NO OF NO OF -CHECK
License Number ^ 'T "l o Class SIZE - STORIES FAMILIES ONE
A :> y . t - - - s- _ VALUATION t
'Contractor '1 • , Dote DESCRIPTION OF WORK T MOJ ~ NEW -❑ -
_ 1 i.' FO uZE ' W ;,Z-N.
.ADO_..,❑ "'s J• v
• ❑ am exempt under-Sec " --- 4 T•i._` ►
ALTER -. n
•B 8P C`-for this reason ��- - - r- • - $
r _ USE OF REPAIR
' Date - EXISTING LIDS- 'C/S I�C'VT' ` DEMOL+ - T • - -• _ '�
+ Signature • ff• - - ,, _ APPLICANT TEL
,. r FINAL
OWNER-BUILDER DECLARATION ;e _ 'DATE
• I hereby affvT m that I am exempt from the Contractor s License _ r - _ , _ i' _,. :I jrs• f t 1
' Low for the following'reason (Section 7031 5, Busmess and ^- ADDRESS FINAL
` -`Professions Code) ESENiBY
BUILDING
s
1 5 ❑ I as owner of the property, or my employees with ADDRESS
e - wages as their sole compensation„will do the work and - - . - - +- +;——i --? •r c - -
the structure is not intended or offered for sale(Section r LOCALITY
7004,.Busmess and Professrons,Code S MOVING „ _. TEL
I, as owner o,the property am exclusively contractmg CONTRACTOR NO1�911
1,with licensed contractors,to construct the project (Sec • ++ ADDRESS - - - .-- - 4 t, - -• - .• �'`Ij '+ --, + • 1''5 1-
hon 7044, Business and Professions Code ) - t
REQUIRED TOTAL SETBACK FROM, IST
CONSTRUCTION LENDING AGENCY �. - SET BACK -YARD` HWV, PROP LINE WIDTH
' I hereby affvm that there is a”construction lending ogency,for ' .FRONT - TOTAL i.: .291� •�;\
the performance of the work for which this permit is issued - - ' P L -- - - - '" }
(Sec 3097 Cv C ) a SIDE - ..i , HECK .Si25.'a,
-PL
'Lenders Name - - r CHANGE a 'i +,LID
y p L)MA Ref N
^ e Perm,i Fee
' Lender s Address �/ t • t
I cern fyUIn have read this apphc nand state Thai the hsuon�e Fee _a/- 7S.- LDMA P/C p' ► C1011}-13001
aba rm ion is correct I a to comp with all County ev"ittatmn Fee _ _
ordm c r XpleoF
ing construction r- .' Total Fee - 4 LISMA Perm p Qyt`'j7
and era uthon a re se County to enter y •_ _ .r.
ection purposes 71 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sgnatu of Ap ant ar Vont Dote r ✓ •' - - - < - r-