HomeMy Public PortalAbout4807 BALDWIN AVE_Building_01/29/1985 �r�2!KERS COMPENSATION DECLARATION -
a+ insure oracertificate rof Wo ke srlCompensat on Insurance APPLICATION FOR BUILDING PERMIT IL
or a certified co th reof (,�,ec 3800 Lab C ) _ -
C41CZ GZta2gy t4 , 4 U7UA L COUNTY OF LOS ANGELES BUILDING AND SAFETY _I
Po cy o a Company - -
❑ Certified copy +s hereby furnished + a FOR APPLICANT TO FILL IN BUILDING'
t ADDRESS
n/Certified copy is filed with'the county building inspec BUILDING � JAJ
- C
iv' tion department+ ` `� ADDRESS
Date 2l Applicant CITY ZIP LOCALITY M r
CERTIFICATE OF EXEMPTION FROM WORKERS ' - -- - NO OF BLDGS - - - NEAREST,., E
r` k COMPENSATION INSURANCE SIZE OF LOT A NOW ON LOT CROSS ST
(This section needinot be completed if the permit is for one -� 1 _ _ ASSESSOR - - T
hundred dollars ($100)orkless ) y� TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL
` i � TEL ` - USE ZONE MAP
I certify that in the performance of t^he,work for which this OWNER ^NO - NO ` J
permit is issued I shall not employ any person in only manner y SPECIAL - d
so as to become subject to the Woikers'Compensation Laws ADDRESS �� �t CONDITIONS it ^ U
DateAepplcant CITY ZIP
ARCHITEC
TEL
NOTICE TO APPLICANT If after making" this Certificate of ENGINEER NO DISTRICT GROUP TYPE_ tl _ FIRE _PROCESSED BY
Exempton you should become subject to the VWorkers - CON ^T ZONE rj
Compensation provisions of the LaboriCode you must forth t ` � j 2j �- 161r- W
P P ADDRESS - -� &
with comply withs.such provisions or this permit shall be - - H
EL STATISTICAL CLASSIFICATION APT CO DO Z
deemed revoked , 1 CONTRACTOR O
LICENSED CONTRACTORS DECLARATION �� LIC - CLASS NO DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 _ ADDRESS �! Z-,W� NO 7
(commencing with Section 7000)of Division 3 of'the Business and oo LIC SEWER MAP
Professions Code and ry license is in full force and effect CITY �!� 7Z CLASS �Q BK PG - ; VALIDATION -
qq SQ FT NO OF _ NO OF CHECK L Jh
License Num+er I �`'� ` ° t Lc Class r O SIZE STORIES FAMILIES ONE'
' + ' /tl�� 'Y f.6 / D VALUATION
DESCRIPTION OF WORK = 1 1 NEW rQ ! bb
Contract V Date �� �✓ ADD ❑ $4d V4qoe _t _
❑ I am exempt under Sec t V : 1 �� ����° LL�����..���r�ss�� `� �� ALTER ,�+� //(
. 3 0h - X)U REPAIR ❑ �— 14 3 A_ t
8 8P C for this reason j S -'
o • 0 0
" Date - - EXISTING BLDG Q/ f 1 DEMOL ❑ 2 3 I
a Signature -4 - APPLICANT TEL FINAL - n ) • ° 5 1 3- _
OWNER BUILDER DECLARATION PRINT N 3 Z g I - 0 0 0 5& 1 32:
_ DATE -
I hereby affirm that I am exempt from the Contractor s License q S 0 1 2,9=85
Low for the following reason (Section 7031 5 Business and ADDRESS / FINAL a
Professions Code) p -ByBU LDING
❑ ,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 4t
7044 Business and Professions Code) MOVING- -^ TEL - - n
❑ I as owner of the property am exclusively contracting CONTRACTOR NO 1 2 15 TQ A'
with licensed contractors to construct the project (Sec
tion 7044 Business and Professions Code) ADDRESS ° # s o s e e 1`
` - CONSTRUCTION LENDING AGENCY- _ RK FROM
ETQBACKUIRED YARD HWY -TOTAL ETPROACNE WIDTH -
I hereby affirm that there is a construction lending agency for FRONT ^ o e 8 '.�8� t `t
the performance of the work for which this permit is issued -P L - t - - - -+- i - +
(Sec 3097 Civ C )n ►,` SIDE ' {He • - 87386
m C9u1 AUC l�- _ - - P L _ _
Lender s Name '
w _ Jr�t13^` LDMA Ref q o •—tet 0 2 2 1 -85
Lender s Address
N)90 0 Rb
w l G C Neo • � t �` 1
_I certify that I have read this application and state that the - _ T 0 1 - Issuance Feel LDMA P/C# o fll c
above information is correct I agree to comply with all County Investigation Fee qp �`� ,I �p o
$ ordin _ s d s elatinV Id ng construction Total Fee r13p LDMA Per #Jori 1N�
u o er o e sentotis County to enter
on o o pro ps ion purposesCH
SEE REVERSE FOR EXPLANATORY LANGUAGE ~
+9n PPlcant or Agent Dote
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