HomeMy Public PortalAbout10634 OLIVE ST_Building_8/5/1988_ROOF SHINGLES WORKERS'COMPENSATION DECLARATION I
tt I 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 a 38 Lab C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
�.. Policy No. Company BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county buIIdin i.Fpec- BUILDING
tion department. fir"' ADDRESS )?
rr L '
Date (��- J � Applicant�� • �"''—"' CITY � ZIP LOCALITY r1 yvL'I ,r ,C•,f,
•' CERTIFICATE OF EXEMPTION F OM WORKERS' r ✓"'�•
COMPENSATION INSURANCE NO.OF BLDGS. NEAREST
RANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one1 / JASSESSOR
hundred dollars($100)or less.) TRACT C BLOCK LOT NO. MAP BOOK PAGE PARCEL
1 TEL. USE• ONE MAP
I certify that in the performance of the work for which this OWNER �l a � NO. NO.
permit is issued, I shall not employ any person in any manner U d c(cf/ d f SPECIAL };
so as to become subject to the Workers'Compensation Laws. ADDRESS / CONDITIONS 0
CITY (,1 Ll ZIP 0
Date Applicant
NOTICE TO APPLICANT: If, offer making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY W
ENGINEER NO. 01 `7 CONST. ZONE / W
Exemption, you,should become subject to the Workers' L~ .___1 �` I ,
Compensation provisions of the Labor Code, you must forth- ADDRESS ' 6� � ') V
with comply with such provisions or this permit shall be r e ! 1 .,P r
10*
deemed revoked. CONTRACTOR t-GOT fret / NO.��/f' ' STATISTICAL CLASIFI�TION APT. CO
LICENSED CONTRACTORS DECLARATION ����n LIC, c� CLASS NO. DWELL. UNITS W
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS/0F;-9 r v o W o o C N - J
(commencing with Section 7000)of Division 3 of the Business and y. LI S L7Xd U SEWER MAP
Professions Code, and my license is in full force and effect. CITY / C CLASS BK PG VALIDATION
rSQ. FT. NO.OF NO.OF CHECK
License Number 2- s �� 1c.Cla ' ~ 3 SIZE STORIES ILIES ONE VALUATION
.r a
2,
�Y�O R
Contractor + Date `p 5—0? DESCRIPTION OF WORK f t�4" �'�" "Q NEW ❑ Yb
$ +� J pill.ADD ❑ r'�
❑ I am exempt under Sec. �° -` ❑
J / ALTER
B.BP.C. for this reason REPAIR ❑ $
USE OF IV
Date: EXISTING BLDG. DEMOL ❑ yr o
Signature g
Si APPLICANT TEL. ii TS
) �V lt� Q Gly G ZZ 9 ,
OWNER-BUILDER DECLARATION PRINTth Pd` NO. DATE FINAL 1.°„° G c”5
I hereby affirm that I am exempt from the Contractor's License ADDRESS '0 L(/ � y,s. '� C ° o•,e,J ni•255
Law for the following reason (Section 7031.5, Business and •FINAL ' C
Professions Code): PRESENT By �,G`�`•��
F-1BUILDING
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. SPECIAL
❑ CONTRACTOR NO.
I, as owner of the property, am exclusively contracting INFORMATION
with licensed contractors to construct the project (Sec- ADDRESS ON REVERSE
tion 7044, Business and Professions Code). SIDE
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTA SET SETBACK
WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
LDMA Ref. N
Do
Lender's Address P.C.Fee$ Permff F05 .}
L I certify that I have read this application and state that the '
3 y PP Issuapce Fee LDMA P/C q
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, J "
and hereby authorize representatives of this County to enter Total Fee LDMA perm. #
$ upon the ab' rNione pr er or inspection purposes.q
$ ��(�/ �%.�rG 'c--- gp- —S� , SEE REVERSE FOR EXPLANATORY LANGUAGE
a '
Signature of App i ant or Agent Date