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HomeMy Public PortalAbout4901 RIO HONDO AVE_Building_6/10/1983_RELOCATE GARAGE AND BUILD NEW GARAGE WORKERS'COMPENSATION DECLARATION insure erebor a certif caaffirm tte of Workers''Compen at ificate of on ent Insuran tolse, "r �►P P L 1 CAT I O N FOR "WILDING P E RM I T or a certified copy thereof(Sec. 3800, Lob. C.) I COUNTY OF LOS ANGELES BUILDING AND SAFETY �• Policy No. Company j Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING �Jbt ADDRESS I /'L f D �}/V Certified copy is filed with the county building inspec- BUILDING �( tion department. ADDRESS 0 /� LOCALITY !/ t' -5114) C ,/ CROSS ST. Date Applicant CITY 94" 2 ZIP 4J4.44 A1016AL CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL +1 r (This section need not be completed If the permit is for one USE ZONE MAPTRACT BLOCK LOT NO. NO. O��! hundred dollars($100)or less.) TEL. _ y� SPECIAL /�� 1• I certify that in the performance of the work for which this OWNER f AN, dm) NO. "�:�`' CONDITIONS CL permit is issued, I shall not employ any person in any manner / DISTRICT GROUP TYPE FIRE PROSSS,,,SSSED BY Q so as to become subject to the Workers'Compensation Laws. ADDRESS � /,Z/'' . (ie,4,1/Y t•0 r�/ ye a COQ}BI�7 ZONE �Ji� V Date Applicant Im CITY ( e C.r� ZIP f'7 lJ STATISTICAL CLASSIFICATION APT. CONDO. NOTICE TO APPLICANT: If, after makingthis Certificate of ARCHITECT OR TEL. R Z „� j — ENGINEER NO.?.8��� ;, CLASS NO.- DWELL. UNITS Exemption, you should become subject to the Workers' fS, Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be TEL deemed revoked. CONTRACTOR NO. BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. IMP I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. �r �r Professions Code,and my license is in full force and effect. CITY CLASS $ t+18"© i!0 SQ. FT. NO.OF NO.OF CHECK License Number Lic.Class •SIZE STORIES FAMILIES ONE ContractorDate DESCRIPTION OF WORK AOVA V�Y Gl`/ '^ N ❑`EW : I am exempt under Sec. to R e A.0 C iiii 6A ADD E]' ALTER E] FINAL / DATE J �� B.&P.C. for this reason el REPAIR ❑,. Date: FINAL EXISTING BLDG. ' DEMOL ❑ By APPLICANT TEL. Signature PRINT NO. 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): PRE ENT f'ti'1 .BUILDING LTJ 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. 2 7 1.5 I,as owner of the property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS {, 0 a a a o tion 7044, Business and Professions Code). • REQUIRED TOTAL SETBACK FROM EXIST. Q o - 7800 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT c c O G the performance of the work for which this permit is issued P.L. tSec. 3097, Civ. C.'). SS IDE () 6 1 0-8-4 0 Lender's Name L 3 P.C.Fee$ Permit Fee J O Lender's Address I certify that I have read this.application and state that the Issuance Fee 0 rJ� above information is correct. gree to comply with.all County Investigation Fee Total Fee ; ordin s and State la re citing to building construction, , and er y outhori r es ntativ of this County to enter up Yh above- t• rope for inspection urp ses. I k SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Applicant or Agent ate ®s