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HomeMy Public PortalAbout9415 BLACKLEY ST_Building__ } w WORKERS'COMPENSATION DECLARATICLN,; �� { hereby affirm-that I have certificate of consent b self ,r( �`� APPLIC FOR BUILDING' P E RM I T insure, or a certificate of;Worr Comp kers' Com ensation Insurance, or a certified copy thereof (Sec 3800`, ,Lab�C )/� COUNTY^OF LOS ANGELES s BUILDING AND SAFETY Policy No - t-/6 Company 5/� ` Certified copy is hereby furnished FOR APPLICANT TO FILL IN.- ADDRESS Certified copy is filed with the county building mspec- BUILDINGY T s do de rtment ADDRESS a/U - + LOCALITY �� - �/ NEAREST Date 0 6 Applicant �u�-- �i- CITY �� (� U ZIP t" CROSS ST 17CEI61FICATE OF EXEMPTION FROM WORKERS' NO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT / MAP BOOK PAGE PARCEL (This section need not be completed if the perrnif is for one USE ZONE MAP hundred dollars ($100)or less ) TRACT BLOCK - LOT NO NO L r. {' TEL SPECIAL I certify that=in the performance of the work for which this OWNER 557 e, Wrr- :::� ` b NO CONDITIONS IL permit is issued, I shall not employ any person in any manner ADDRESS J 6(�c� 4�1� ISTRICT GROUP TYPE FIRE PROCESSED BY O so as to become subject to the Workers'Compensation Laws CONST / ZO U CITY /� G/ ZIP - �(?V" f /vJ o Date Applicant ARCHITECT OR TEL STATISTICAL C SSIFICATION APT ]CONDO F� NOTICE TO APPLICANT If, after making this Certificate of _ ENGINEER NO CLASS NO DWELL UNITS a Exemption, you should become subject to the Workers' ' Compensation provisions of the Labor Code, you must forth- ' ADDRESS - - - -^ - - SEWER MAP H with comply with such provisions or this permit shall be ' �F ��—75 7 deemed revoked CONTRACTOR W�5 r4 A� P,/q'('C(TMA- OL r BK -- PG, VALIDATION .' LICENSED CONTRACTORS DECLARATION / n LIC • it hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 766 C � �5 NO 39366? - VALUATION (commencing with Section 7000)of Division 3 of the Business andLIC ! 6 " Professions Code, and my license is in full force and effect CITY 6LJA UT- CLASS a yr $ , �-1}�/, ��7,e� SQ FT i1 !-3 NO OF NO OF CHECK License Number v(��" LicYCjass SIZE o`E� STORIES FAMILIES ONE to6-1rT �dR �GGl57Dw�/1Ar/O p �� S t w DESCRIPTION OF WORK //UcS�A(�� NEW 'Contractor Date ADD I am exempt under Sec ✓y►tJJ�, L_ T7( Cf�f� Z ALTER FINAL DATE B&P.0 for this reason CY ©/e- P « � /F1Lt'N� ❑ REPAIR ' Date USE bFEXISTING BLDG 1 t �. V . DEMOL E] By AL Signature APPLICANT (,�, TEL OWNER-BUILDER DECLARATION - (PRINT) V �C.�fC GrC H� NO S�N'�� I hereby affirm that I am exempt from the Contractor's License ADDRESS 718-C- PrN fir -C.S ► R- 1 51,01 Law for the following reason (Section 7031 5, Business and - / •` _ •' Professions Code)" B 23 BUILDING `� ` � { I,;as owner of the pfoperty,�or my employees with ADDRESS L� 0 0 4 �,�1 5wages as their sole compensation,will do the work and / c the structure is not intended or offered for sale(Section LOCALITY - // i o 0 0 4 1.14 5 v 7044, Business and Professions Code) MOVING TEL ❑Y CONTRACTOR - NO G I, as owner of the property, am exclusively contracting 9.29-84 with licensed contractors to construct the project (Sec- ADDRESS ' ' `� , d 2 4:5'1, 1 A tion 7044,-Business and Professions Code) _ CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBACK FROM EXIST o o e a o SET BACK YARD HWY PROP LIN WIDTH' _ I hereby affirm that there_is a construction lending agency for _FRONT + • w - ® 2 ro+o Jr 4 2 S r the performance of the work for which this permit is issued P L b r (Sec ,3097, Civ C) A SIDE - o 0 0 5 4,2 5 6 m - PL r t o Lender's Name 0 C. 2 8-8 4" 5 P C Fee$ Perma Fee Lender's Address ` I certify'that I have read this application and state that the Issuance Fee �r - above information is correct I agree to comply with all County Investigation Fee ordinances and State jaws relating to building construction, Total Fee and,hereby authorize representatives of this County to enter upon the above-m n oned prop rty for inspectio urp ses T SEE REVERSE FOR EXPLANATORY LANGUAGE _ w Signature of Applicant or Agent Date ®s