HomeMy Public PortalAbout10631 OLIVE ST_Building_8/20/1984_PATIO SLAB AND ROOF WORKERS'COMPEN .ATION DECLARATION
hereby affirm that I have J.certificate of consent to self l 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
Policy No. Company BUILDING I
� //Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS o 6�7 1—�s
�7/Certified copy is filed with the county building inspec- BUILDING ,
LLLLLLJJJJJJ tion department. ADDRESS fV ® f LOCALITY
Q �//✓ : NEAREST
Date. O Applicant Vim/ l� (1L3 CITY any �� ZIP CROSS ST. r2�
CERTIFICATE OF EXEMPTION FROM WORKERS' N OF BLDGS. -ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO.
TEL SPECIAL
I certify that in the performance of-the work for which this OWNER _ NO '- �'1 CONDITIONS
permit is issued,i shall not employ any person in any manner /` > DISTRICT 12PI
TYPE FIRE PROCESSED•BY V
ADDRESS QtO .Q4 v'g CONST. ZO E
so as to become subject to the Workers'Compensation Laws. Ix
'�-- L� ®
Date Applicant : CITY �2 ZIP STATISTICAL CLASSIFItATIONPi. CONDO. 11-
NOTICE TO APPLICANT: If, after making this-Certificate of ARCHITECT OR TEL. M
Exemption, you should become subject to the Workers'
_DWELL.UNITS-
ENGINEER NO. CLASS.NO.
Compensation•provisions of•the Labor Code, you must forth- gDDRESS SEWER MAP
with comply with such provisions or this permit shall be /11
deemed revoked. CONTRACTOR ,�(, t&, NO. s-O BK• PG. / VALIDATION -
LICENSED-CONTRACTORS DECLARATION LIC. r���•,,�� 7//'
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS.VeA!� + NO 7't?'' _3Y- VALUATION
(commencing with Section 7000)of Division 3 of the Business and• { , LIC.
Professions Code, and my license is in full force and effect. CITyA e, ,4d 4 CLASS $ ,
�/• (� / SQ.R. NO.OF NO.OF CHECK'
License IsumbeAr �/�R' .Lic.Class-49 SIZE STORIES ]FAMILIES
ONE
Contractof�/^'1✓ xis J� Date I+ DESCRIPTION OF•WORK ¢2�/�J la NEW ❑ $: "
a ❑I am exempt under Sec. Cx� ADD ❑
• ALTER ❑ FINAL
B.&P:C. for this reason REPAIR ❑ DATE
USE OF FINAL
Date: � DE 'L
l EXISTING BLDG. ❑ BY
Signature APPLICANT TEL.
OWNER-BUILDER DECLARATION
I hereby affirm.that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT `
BUILDING
1,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 --P,3 6 2.1 A
7044, Business and Professions Code). kADDRE
TEL.
I,as owner of the property,am exclusively contracting TOR NO. o_0 0 0 0 1
with licensed contractors to construct the project (Sec- I
'tion 7044, Business and Professions Code). 2 0I° 5 9.2 5
D TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY K YARD HWY PROP.LINE WIDTH o o a (� '�Jr-v
I hereby affirm that there is'a construction lending agency for
the performance of the work for wh";h this permit is issued 0820-84
tSec. 3097, Civ. C.,). I
n
`e Lender's Name
3 Permit Fee
Lender's Address
r. I.•certify that I,have read this application and state that the Issuance Fee
above information is correct. I agree to comply with all County . Investigation Fee 11 J'--'
ordinances and State laws relating to uilding construction, Total Fee
and hereby authorize repress ativ o this County to enter
upon th v -mentioned ops for.Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
_at re of A p(cant r Agent Date _ :®s