HomeMy Public PortalAbout4836 BALDWIN AVE_Building__ *k WORKERS' COMPENSATION DECLARATION
hereby affirm? that I have certificate of consent to self APPLICATION FO BUILDING P E RM I T
insure, or a certificate of Workers' Compensation Insurance, - A
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. ti Company
E] BUILDINGS J _
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS c�(p
❑ Certified copy is filed with the county building inspec- BUILDING 2
ADDRESS J
tion department. A�p/
Date Applicant CITY lC ✓[/ / ZIP LOCALITY
pp NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 42 NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR �( ( / )
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. z MAP BOOK 5 t) PAGEWlhyn� PARCELV
.hundred dollars ($100) or less.). OWNE M j N(WIr — USE ZONE NO.MAP �r7�
�y
I certify that in the performance-of the work fay which thisNn SPECIAL
permit is issued, I shall not employ any person in any manner ADDRE I& CONDITIONS
so as to become subject to the Workers'Compensation Laws. OV
CITY �I ZIP
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE. FIRE PR ESSED BY O.
NOTICE TO APPLICANT: If,.after making this Certificate of ENGINEER NO. CONST. E U
Exemption, you should become subject to the, Workers' ��// '/
Compensation provisions of the Labor Code, you must forth- ADDRESS v� y N
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. �_DWELL. UNITS
—
LICENSED
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. q. NO. OF NO. OF CHECK
License Number ' Lic. Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIIPtTION OF WORK NEW El
ADD $ O D�0
El am exempt under Sec.
l/V1T11 F! f}C1� 1�� IJ ►
7 J3 ALTER ❑
B.&P.C. for this reason � /�� C/� REPAIR ❑
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANTFINAL
NO.
OWNER-BUILDER DECLARATION DATE �2• — �/
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT By T
BUILDING +•--`j"_
❑ 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. - v
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec-
FADDR
tion 7044, Business and Professions Code.)
TOTAL SETBACK FROM EXIST. •: _ '
CONSTRUCTION LENDING AGENCY YARD HWY PROP. LINE WIDTH ""t - �i-'=
I hereby affirm that there is a construction lending agency for )'i_j ;
the performance of the work for which this permit is issued -
(Sec. 3097, Civ. C.).
Lender's Name p C.'
� Permit Fee ;-:I;.Lender's Address1 certify that I have read this application and state that the Issuance Fee �7 7LDMA P/C# ►above information is correct. I agree to comply with all County Fee � � / �j
o .ordinances and State laws relating to building construction, Total Fee / LDMA Perm. # 3 ss s?+,_f"s_;h
a and hereby authorize re resentatives of this County.to enter .4 1.1•
upon he
apo entio ed'property for inspection purposes. _y
! SEE REVERSE FOR EXPLANATORY LANGUAGE _
Signature of'Applicant or Agent ate .