HomeMy Public PortalAbout9018 RANCHO REAL RD_Building_6/23/1986_add bathrm to 2nd flr,patio cover %,".KERSuCOMPEN�SATION DECLARATION
hereby'j ir,m that 1 have a certificate of consent to self ®� WN Y R BUILDING PERM!T cU
insure, ora certificate of Workers'Compensation Insurance, 6'�
or o certified'copy thereof(Sec. 3800, Lob. C.)
.. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.—' Company BUILDING
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❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
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❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Date Applicant CITY 92AS a ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON OT CROSS NEAREST.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK 01 PAGE PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this OWNER , ¢ O. — n NO.
JIL
permit is issued,I shall not employ any person in any manner Y SPECIAL
ADDRESS
so as to become subject to the Workers'Compensation Laws. �1, CONDITIONS U
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Date-11--D-96 Applicant • CIN ZIP
NOTICETO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT DISTRICT GROUP TYPE FIRE PRO SSED BY
ENGINEER ¢O• y/ 0� n 2 CONST.VNE
Exemption, you should become subject to the Workers' Ip/� Jl �
Compensation provisions of the Labor Code, you must forth- ADDRESS t b .• y
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. LNDO.
.deemed revoked. '. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. �' DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business andLIC, SEWER MAP f
Professions Code, and my license is in full force and effect. [ CITY � I"C?' CLASS BK. PG. b/ VALIDATION
e:SQ. FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE / STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK lull NEW
Contractor Date $
ADD ❑ 7 �J
❑I am exempt under Sec. OIYI G
19
Pilo
ALTER ❑
B.BP.C. for this reason kAg• REPAIR
❑ $
Date: : EXISTING BLDG. o��r� Fl C(i DEMOL ❑ #
Signature APPLICANT TEL. FINALf� 1
g OWNER-BUILDER DECLARATION (PRINT) °1 NO. ' — DATE `� � ( 0 o57,38
I hereby affirm that I am exempt from the Contractor's License ADDRESS FI / �?r 0 0 0 .5'],3
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT
�� -�% 0612-86
❑ BUILDING
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 offeregfor sale(Section LOCALITY
7044, Business and Professions Code) MOVING TEL.
,f CONTRACTOR NO.
I,as owner of the property,am exclusively contracting ;P2 4 8 7 0 A
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). # 0 0 0 0 0 1
REQUIRED YARD HWY TOTAL SETBACK FROM IT
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT ° ° 7 8
oo
the performance of the work for which this permit is issued P.L. r
(Sec. 3097, Civ. C.). SIDE o 0 - 7a(003
P.L.
v_ Lender's Name 4,0114P—
LDMA Ref. # 0 623-86
i
P.C. Fee$ Permit Fee
L ( 5
Lender's Address
x I certify that I have read this application and state that the Issuance Fee c/ LDMA P/C#
' bove information is correct. I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction, Total Fee LDMA Perm.#
J c(nd hereby authorize representatives of this County to enter
I upy/ 1-e above-mentioned property for inspection purposes.
aI)�; ._� a �. —/a ` SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sigrof Applicant 4r Agent Date
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