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Home My Public Portal About6222 BURTON AVE_Building__ t WORKERS'COMPENSATION DECLARATION X�`L nf;- ,6cicm;ifico hover certificate of consent to self APPLICATION FOR BUILDING PERMIT Il - a0ur3;aL4 certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lob. C.) PQccnyio9 � COUNTY OF LOS ANGELES BUILDING AND SAFETY o icy No. Company IZ'41n Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN ADDRESS as U fC"Y' Certified copy is filed with the county building inspec- 'BUILDING LN tion department. O�l ' ' /�O ADDRESS LOCALITY Date SSApplico CITY ZIP ��D NEAREST CROSS ST. CERTIFICATE OF EXEMPTION M WO I S' NO, OF BLDGS, ASSESSOR COMPENSATION INSURANCE SIZE OF LO7 gOXaro NOW ON LOT MAP BOOK PAGE PgRCEt (This section need not be completed if the permit is for one USE NE MAP hundred dollars ($100)or less.) TRACT S& BLOCK LOT NO. _ NO. TEL. SPECIAL y I certify that in the performance of the work for which this OWNER NO, J / CONDITIONS ly permit is issued, 1 shall not employ any person in any manner r DISTRICT GROUP TYPE FIRE PROCESS BY O so as to become subject to the Workers'Compensation Laws. ADDRESS 7 0 t 3 CONST. / ZONE / O Date Applicant CITY ZIP STATISTICAL CLASSIFICATION ,V/ APT. CON l'- NOTICE OR TEL. NOTICE n, APPLICANT: If, otter making this Certificate of ENGINEER *00 CLASS 2 V Exemption, you should become subject to the Workers' CtA55 NO. DWELL. UNITS_ Wa Compensation provisions of the Labor Code, you must forth- ADDRESS In SEWER MAP with comply with such provisions or this permit shall be TEL. VALIDATION Z deemed revoked. CONTRACTOR NO, BK. PG, LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ?�S NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and �, LIC. Professions Code, and my license is in full force and effect. CITV 7� (i-G CIA S o ► n �� OF 67 NO.OF CHECK < 9 License Number T��7J - Lic Class SIZE $TORIES Oc FAMILIES / ONE E #a,� e d f- 51-1-119-S� DESCRIPTION OF WORK NEW Contractor �L�A Date ADD ❑ 1 I am exempt under Sec. S ALTER FINAL B.BP.C. for this reason S REPAIR DATE Q 9. 1 8"85 USE OF ❑ Date: EXISTING BLDG. SF G DEMOL FI Signature APPLICANT I TEL. OWNER-BUILDER DECLARATION PRINT NO. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS ' Professions Code) RE r 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. %• 1\ j /• ' ETI, as owner of the property, am exclusively contracting CONTRACTOR NO. ' with licensed contractors to construct the project (Sec-Code).- ADDRESS tion 7044, Business and Professions Code).- 3 3 t.2 A REQUIREDTOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LIN WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. Sec. 3097, Civ. C.). SIDE 1 - 809.25 P.L. m Lender's Name, / Q- q �J B e 809.256 $ �f�i4 P.C. Fee$ 6-7 Y t !r Permit Fee [ 1 0,28-85 Lender's Address _ I certify that I have read this application and state that the Issuance Fee /0,30 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee d and hereby authorize representatives of this County to enter - ' U pon the above-m 'property for inspections purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE igna,u e o pf a of or Data ®s •+�� WORKERS'COMPENSATION DECLARATION cl sure, or affirm that haver certificate of consent to =elf - - APPLICATION FOR BUILDING PERMIT c insure, or a certificate of Workers' Compensation Insurance, or o certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TOTFILLIN BUILDING 7 7 ADDRESS J [� Z QCertifiedcopy is filed with the county building inspe BUILDINGion depart ent. J a7 Q, ADDRESS 2 7-•Dale ^Applicdnt' '] 'lam CITY LOCALITYERTIF ATE OF EXEMPTION FROM W RKERS' No. Oy NEARESTCOMPENSATION INSURANSIZE OF LOT NOw !� CRO55 ST. (This section need not be'completed if the'permit is for one TRACT BLOCK . ASSESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL �— TEL USE ZQNE MAP I certify that in the performance of the work for which this OWNER f NO. O D sIFJ I NO. I/ } permit is issued, I shall not employ an person in an manner / SPECIAL - Id so as to became subject to the Workers'Compensation Laws. ADDRESS 2� C CONDITIONS u CITY ZIP OC Dale Applicant ARCHITECT OR TEL O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP CONST ZONE PRO SSED BY U Exemption, you should become subject to the Workers' W Compensation provisions of the Labor Code, you must forth- ADDRESS J [Jd y with comply with such provisions or this permit shall be TEL deemed revoked. , . STATISTICAL CLASSIFICATION APT. NDO. Z CONTRACTOR NO. L LICENSED CONTRACTORS DECLARATION .- �•i LIC. n CLAb SS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS r V, NO. 6!y (commencing with Section 7000)of Division 3 of the Business and LIC q �-t _ SEWER MAP Professions Code, and my license Win full force and effect. CITY i" a CLASS C VALIDATION 2' 'gyp— 2 C 50 FT. 9Q7 STORND.OES FAMIF 110LIES CHECK l License Number �Lic.Class i Z e 2/ SIZE ONE 1-1 VALUATION _ Contractor• ate 0 L ,S� DESCRIPTION OF WORK '_ NEW ❑ I am exempt under Sea. - ADD � $ , ALTER BAP.C. for this reason REPAIR ❑ $ Date: USE F EXISTOING BLDG i e DEMO" Signature � APPLICANT�, TEL / FINAL O NER-BS/f ER DECLARATION (PRINT) tLE No. 241/`L}y3y DATE - Ihereby affirm that I amt empt from the Contractor's License �� FINAL Low for the following. anon (Section 7031.5, Business and ADDRESS i -Professions'Code):' PRESENT - BY ❑ BUDDING /�q ' 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 ,pll./ xly/ 7044, Business and Professions Code). MOVINGTEC. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). �/f /.� J 233 IL 1 A CONSTRUCTION LENDING AGENCY- SETT BACK YARD HWY TOTAL PROP. LINE ETBACK FR WIDTH - {-1 v, I hereby affirm that there is a construction lending agency for FRONT j # 0.0 ° ° ° 1. the performance of the work for which this permit is issued P.I. - - (Sec. 3097, Civ. C.). SIDE' ( • * 60 5 0 P.I. m Lender's Name S Ill �pl LDMA Ref. If ° ° 060,505 Lender's Address P.C. Fee$ Permit fee `JL/ 1! ' -I_certif that I have read this application and state that the /0'3�u ( 2 9—a 5 y pp Issuance Fee LDMA P/C IF a W above information is correct. I agree to comply with all County Investigation Fee fT t ordinances and State laws relating to building construction, Total Fee go 0 - and hereby m orize raprese olives of this County to enter LDMA Perm. q � upon the ov -mentioned operty for inspection purposes. r SEE REVERSE FOR EXPLANATORY LANGUAGE $ignaWre of plimnt or Agent - t - - �° �