HomeMy Public PortalAbout6445 TRELAWNEY AVE_Building_8/2/1989_ WOWRS' COMPENSATION DECLARATION
hereby d cer that I*f W r certificate of consent to self APPLICATION F. R. BUILDING PERMIT
ir(sure, or a certificate of Workers Compensation Insurance,
ora certified copy thereof (Sec 3800, Lab C ) iiR
COUNTY OF LOS ANQELESl BUILDING AND SAFETY
s ' Policy No Company
BUILDING L 14 �
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
IJ Certified copy is filed with the county building inspec- BUILDING-
non department ADDRESS
CITY ZIP / 7 O LOCALITY
Date Applicant NO OF BLDGS
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT iC/ NOW ON LOT CROSS
CRO55 ST Vnin! in, ink
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for ossa TRACE MOCK LOT NO MAP BOOK PAGE PARCEL
hundred dollars ($100)or len ) TEL USE ZONE MAP
OWNER !�- A /�10 �-
I certify that in the performance of the work for which this SPECIAL y
Permit is issued I shall not employ any person in any manner ADDRESS ..S T /V I CONDITIONS M
so os to become subject to the Worke Compensatio Laws O
CITY ZIP U
/SAO-q0
Date Applican AEff OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY W
NOTICE TO you SANT If er mabjec tto ficok of ENGINEER D /c/ _'CW 140 �`=C O(L 'J ODNST ZONE
Exemption, you should become subject to the Workers' 4U, 3
Compensation provisions of the Labor Code, you must forth- ADDRESS l011 AA:�.lN/TaS
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked CONTRACTOR NO
LICENSED CONTRACTORS DECLARATION UC CLASS NO LL UNITS—
LICENSED
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER
(commencing with Section 7000)of Division 3 of the BusmenUC
and Professions Code,and my license n in full force and effect CITY i G'r Mv.SS BK A (DATION
SO IT NO OF NO OF CHECK-
License
License Number LIC Clan SIZE STORIES FAMILIES ONE
VALU TION 3307 342.93
Contractor Date DESCRIPnON $ G 1 ILGILJ
❑I am exempt under SecALTER ❑ pool 342. 9$
B 8P C for this reason REPAIR ❑ $ /�E�A�LM 342.r9�8,
Date D EXISTING BLDG 7E DEALOL ❑ CFIAF" .OU
Signature A�(PR NANT
(� [// Q1(-l..qp FINAL
OWNER-BUILDER DECLARATION DATE rvyyL�M
I hereby affirm that I am exempt from the Contractor's License ..S T��L+4 N�- FINAI 00 1 8/ 229
Law for the following reason (Section 7031 5, Business and ADDRESS
Professions Code) ONMON By 4W 1 Air 9:41
❑ j, as owner of the property or my employees with ,ppDIu ��/))) 1
wages as their sole compensation will do the work and Poo
the structure is not Intended or offered for sole(Section LOCALITY
7044, Busmen and Professions Code ) MOVING TEL
❑ j, as owner of the property,am exclusively contracting CONTRACTOR NO
with licensed contractor to construct the project (Sec- ADDRESS
tion 7044 Business and Professions Code ) 5 c
EX
CONSTRUCTION LENDING AGENCY SET REQUIRED YARD FIW1' TOTAp P LIINNEE A
I hereby affirm that there is a construction lending agency for FRONT C
the performance of the work for which this permit is Issued P L :^� I-'L 4 C� �+ r-•
(Sea 3097, Civ C ) SIDE C I
Lenders Name '
P C Fee S Perms Fee 1 LDM"ef e
Lenders Address /'571-7 `��UGR� S� � R ,
o I certify that I have read this application and state that the in nce Fee t'" LDMA PTC F
above information is correct I agree to comply with all County
Investigation Fee n
ordinances and State jaws relating to building construction, TotalF. LDMA Perm Y 4'
and hereby authorize representatives of this County to enter �/�t '
upon t e above-ment on property Inspection purposes Cc,
^n ���'O^'9D SH F"EM FOR EXPLANATORY LANGUAGE r^I �O 'C' n
Sgnoture of Applicant or Agent Date O — U
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