HomeMy Public PortalAbout5922 BURTON AVE_Building__ WORKERS'COMPENSATION DECLARATION r . I��}I��y���Lgp��L�
insure,
affirm that haver certificate of consent to self - .^ ly�l�yU 1p�T��p�,11 •F®ll�l BURM11 V� II LSU�10V11��
insUr2 or a eertificate-of Workers' Compensation Insurance, - G"l\Il BV• !/"ll (III u v 11 .
qr a certified copy thereof (Sec. 3800t.
, Lab.'C.) - COUNTY OF LOS ANGELES - BUILDING'AND SAFETY _ ..
Policy No. Company
BUILDING �('
❑ _Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ee
I� t2�j-✓
-❑ Certified copy is filed with the county building in spec- BUILDING
tion department., ADDRESS Zy
. - CITY' r ZIP `/7,9 n-. LOCALITY -� -
Date—Applicant 0. OF BLLX 4NEAREST
CERTIFICATE OF'EXEMPTION FROM WORKERS' " SIZE OF LOT — OWON LOT - CROSS ST.
COMPENSATION INSURANCE - - ASSESSOR .
(This section need not be completed if the permit is for.one TRACT BLOCK LOT NO. - MAP.BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL
OWNER ��� .NOZ USE ZONE' NO.
Icertify that in the performance of the work for which this �(Q,Y�,1 ({/.T _
Perim is issued, shall not employ y person in any manner N ADDRESS .moi - /O. /V' ' CONDITIONS 0-
0/ SPECIAL >-
sas to,be
cpp me subject.to the Wo s Compe s.h _Laws.—,,,999 - -�~ - 0
CITY 12 zIP G V
Date S_Cf�G �� i a J ARCHITECT OR / TE. ' tY
NOTICE TO L ANT: If, g71e� dking this•Certificate.of _ ENGINEER NO. .E7/z . DISTRICT GROUP CONST NE
PROCESSED BY
Exemption, you should become subject to the Workers' ' Q , / V
Compensation provisions of the Labor Code,.you must forth- ADDRESS �^ 'PO ' ✓ tea+?-c a
with comply with such provisions or this permit shall be •TEL STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked.' (/ CONTRACTOR NO. - J.♦
z
LICENSED CONTRACTORS DECLARATION - )ILLIC.' - � CLASS NO. DWELL. UNI75 z. ,
I hereby affirm than am licensed under provisions of Chapter 9 DDRESS' / NO. _ a-(commencing with Section 7000 of - LIC. - SEWER MAP
( g ) Division 3 of the - '
and Professions Code,and my license is in full force and effect CITY - CLASS Bk PG (_,VALIDATION
50. R. ' NO. OF NO'OF "CHECK _
License Number - Lic.Class - SIZE STORIES FAMILIES ONE y i ; j';-_•
_ - �Z' VALUATION-, i
Contractor Date 1 Y.\ DESCRIPTION OF WORK ,r I ! 'NEW _•$ r �It _ _ -
❑I am exempt under Sec. `� l J -L(�• Vz 1•/ D ❑ V D �I 'l -
B.BP.C. for this reason y �' rz !V LT ❑ $
USE OF -c,L EVPAI
OL
Date: EXISTING BL 6 - ,l< •� - DE ❑ -
Signature APPLICANT-
NAL
OWNER-BUILDER DECLARATION (PRINT). NOZ Z ZZ'
I hereby affirm that I om exempt from the Contractor's License ti'`-'' >'a, r"' J _ iSt •hv�\? w•k,1Q DATE -zZ Gj'1 F y • y117 y .,
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL, '
PrDfessions Code): . PRESENT' ._ \ .. BY• ._ .�.. i E.�i
/)tL�J�\ BUILDING
I, as owner'of the property; or.my employees with ADDRESS
wages as their sole compensation,will do the work and
the structureis not intended or offered for sale(Section LOCALITY D3 C;Fr�ti dd"7 C\1 ` i 1,iy.
7044, Business and Professions Code.), MOVING - _ TEL. ll�/ 1
N� CONTRACTOR NO. �`3-yr1 g / s
Iql I, as owner of the.property, am exclusively contracting - 11,9 Ar Tf L rL. r
/ \ with licensed contractors to,construct the project.(Sec- - V .Y✓y(l t ,an .-.�
ADDRESS /
tion 7044, Business and Professions Code.) /,e. :7- . '.1' , t. 4F' 't
.REQUIRED YARD HWY TOTAISETBACKFROM .EXIST.
CONSTRUCTION LENDING AGENCY. SET BACK .PROP..LINE .WIDTH 1 �j, f•f
I hereby affirm that there is a construction lending agency for FROM '+ - q -
the performance of the work for which this permit is issued -P.L. - - - . \ -•,
(Sec. 3097, Civ. C.). .SIDE r ,• \ +f Il�E4-F ( i'' • :, /
.P.L..
Lender's Name
q yN� (OA Ref # �laP. 1
m - P G MFee$ ����f• o r� Permit Fee Ola. D -
Lender's Address
a' I certify that I.have.read this application and state that the Issuance Fee LDMA P/C#
8 above information is correct. I agree to comply with all County _ Investigation Fee r� ,t
ordinances and State:laws relating to building construction, Total Fed�``�l `' - LOMA Perm. p
a and her y�en
presentatives of this County.to enter
m 7(rpc fh ed p rt f r ns coon Lr oses.
f % "Y C/ Z SEE REVERSEFOR EXPLANATORY LANGUAGE.
a/ j Si nature of Applicant or Agent - Date