Loading...
HomeMy Public PortalAbout5142 BARELA AVE_Building__ WOrr1KE�S'CQMPENSATION DECLARATION R 3#rrm tr° f have a certificate of consent to self ins' a cer+rC�ate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT � or p c w fed copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished.. FOR APPLICANT TO-FILL IN J BUILDING ❑ ADDRESS Certified copy is filed with the county building inspec- BUILDING ,L,L/ Pion department. ADDRESS 7 !(� `04 f7,6 l C7 Date Applicant CITYT, C, ZIP �, © LOCALITY I CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ,� ©f NOW ON LOT C OSSSST. �{ 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 PAGE PARCEL TEL. USE,ZONE MAP �L I certify thcit'in the performance of the work for which this OWNEk ©SC NO. /v7 NO. permit is.issued, I shall not employ any person in any manner SPECIAL IL /`J /V' Y~ sous to become subject to the Workers'CompensationADDRESS CONDITIONS O Laws. ,V 4^ q CITY 7 E _ ZIP . 1 70 009 Date-5 —A R 407Applicant ARCHITECT OR/ TEL. O NOTICE TO APPLICANT: If, after makingt Ceftificate of ' �J 7 DISTRI T G UP, TYPE FIRE PRO SED.BY Exemption, you should become subject to the Workers' ENGINEER © �(� /NO ( /� 1,9 CONST. ZONE U Compensation provisions of the Labor Code, you must forth- �/ ADDRESS s/9' !> 9- with comply with such provisions or this permit shall be cel deemed revoked. ,7 /f/ /� / TEL• STATISTICAL CLASS IC TION APT. CO O. Z CONTRACTOR C%�iv(T AOZ16 Q. 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 and LIC SEWER P Professions Code, and my license is in full force and effect. CITY CLASS gK PG - VALIDATION SQ. I`Te3 WPS ORIOES AMOES CONEK License Number Lic.Class VALUATION l q DESCRIPTION OF WORK [J ^ NEW ❑ /dj�/ ®7 O 8,.2 A Contractor Dare pG�1 ADD 36' 6{./ z 3 ❑ I am exempt under Sec. " e ltd ALTER ❑ ) - 307,92 B.&P.C. for this reaso I REPAIR ❑ $_ 0 0 3 Q ] Q 2 Date:— USE OF EXISTING BLDG. DEMOL ❑ lt�i f�i�)s '88 Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE 4 1 5 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ' z 7 1 3,4 A ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct-the project (Sec- ADDRESS a ® o •.®.1 tion 7044, Business and Professions Code). REQUIRED. YARD HWY TOTAL SETBACK FROM EXIST. - 372,75 ' CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH 1 hereby affirm that there is a construction lending agency for FRONT o 0 3 7 27 5 5S, the performance of The work for which this permit is issued P.L. 5,2 9"'8 7 (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name m Q �^ LDMA1 Ref. # - - P.C. Fee$ Permit Fee - - Lender's Address _ w I certify that I have read this application and state that the Issuance Fee LDMA P/C above information is correct. I agree to comply with all County Investigation Fee ' m ordinances and State laws relating to building construction, Total Fe )155 LDMA Perm. # d and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE Si Lure of Applic r Agent - Date - - - '- - - -- - - - - - - ©t iI