HomeMy Public PortalAbout9033 CALLITA ST_Building__ WORKERS' COMPENSATION DECLARATION
_. moo. . aPI�dOC�Q� ON FOR. [�NJ�d�P�1C� PCRI�1�
I hvr S' affirm that I have a certificate of consent to self O O
insure, of a certificate of Workers' Compensation Insurance,
pr a certified copy thereof (Sec. 3800, Lab. C.) _ - COUNTY OF SOS ANGELES BUILDING AND SAFETY ..
Polio No. - Company t
`❑ BUILDING
Certified copy is hereby furnished. - FOR APPLICANT TO'FILL IN ADDRESS - 0,33 Gl2GL�7�1 •
Certified copy is filed with the county building�inspec- BUILDING * _ •. ,- - - _.
tion department: �; ADDRESS /� (� {'L LLL R ("']],J
Dole— Applicant
CIN' �I,'`` he)QIGL ZIP "11175 LOCAil7Y
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT(4,5 X I��{r�a NO. OF LOT 'I_ �- CROSSNEARE
NOW ON LOT '
COMPENSATIONINSURANCE - �+ -
ASSESSOR
(This section need not be completed if the permit is for one TRACT ;L5 P,.')." BLOCK LOT NO. 5 MAP BOOK$$' PAGE 4!D /� PARCEL
hundred dollars ($100)or less.) I C TEL
OWNER - NO. - USE ZONE' MAP
.I certify.that-in the performance of the work for which this F^T ` 1 l�.� - / NO.
.permit is issued, I shall not employ any person in any manner ADDRESS 3 A4.1, J' SPEC IAL a
so as to become subject to the Workers' Compensation Laws. - /L -•-'L—� CONDITIONS O
CITY }}pQ EL-' ZIP. I. 1 IS - - U
Date 'Applicant - ARCHITECT OR9(� Q�s ^t��;i TEL. ,( �1 0
NOTICE TO APPLICANT: If,. offer makingthis Certificate of WEER RA JpEHT'LT. NO.y ="/I�a DISTRICT �ROUP TYPE FIRE PROCESSED BY
y Q CONST. ZONE O
Compensation
oExemption,pesat you should become subject' to
the Workers'- I rJI •1r�,i'-A, O D a
Com ensation provisions of the Labor Code, you must.forth- ADDRESS rJ IVL.L'TFI F'I 0 W
with comply with such provisions or this permit shall be TEL, STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. - CONTRACTOR NO. - /� Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 49T—/ DWELL'. UNITS— -
I hereby affirm that I am licensed under provisions of Chapter9 ADDRESS _ - NO. SEWER MAP
(commencing with Section 7000)of,Division 3 o the Business LIC.
and Professions Code,and my license is in full force and effect. CITU � CLASS 1 BK. VALIDATION
SQ. FT NO. OF NO. OF CHECK _
License Number'- Lic. Class SIZE,
Is
I FAMILIES / ONE
VALUATION - >_
Contractor -Date DESC TI OF WORK NEW ❑ 5:!f7 _t4`V t.
r-
'
❑I am exempt under Sec T 1 O i I GL . 95 = OJ
Q ALTER ❑ �oa-o c0 ° 1 -T
8.8P.C. for this reason � � -v • � REPAIR ❑ $ � �.L�,-.i rc;.r I__
Date: USE OF ���,�,,,,,,LL..�� to •..s f�
EXISTING BLDG.V r- cCIz C�� -DEMOL ❑
Signature APPUCIIN'^ 0 ^ ' NO d FINAL -•CH..u� �� -
OWNER-BUILDER DECLARATION PRINT lM. `�
I hereby affirm that I am exempt from the Contractor's License '•Z...ham- , +!-'' �' \�- r �" `♦�� _-`', DATE
Law for the following reason(Section 7031:5,Business and ADDRESS E S� FINAL 1,Ii I B;-•I'N 1I i r1:
Professions Code): PRESENT, �{'_,r _ S`:":.: BY. 1 f'^MLT t
I, as owner of the property, or my employees with BUILDINGADDRESS
wages as their sole compensation,will do the work and LOCALITY - (/' `�. .\`f t'C ��1 �.{}.i_17 1-,_y'•°4
the structure is not intended or offered for sale(Sectiori �1 {
' I
7044, Business and Professions Code.) - -
MOVING TEL. r
I, as owner of the property,.om exclusively Contracting CONTRACTOR NO. _
-Cj
_Z 3 /a O I '.I `d
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) '� `jl7, � ^;y'�'(;+s i.`;-nL ;,i
REQUIRED TOTAL SETBACK FROM EXIST. ._/ /,O�O _
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH F+? J •' �" ECK
H t
I hereby affirm that there is a construction lending agency for FRON7 < 6 1 l• r
the performance of the work for which this permit is issued P.E. J -
(Sec. 3097, Civ. C.). .. . SIDE
- P.L.. it 1.01 7 P11P f 7/0"
l_1 7
$,. Lender's-Nome N v 21r5
P.C. Fees Permit Fee LDMA Re
Lender's Address
_
I certify that I have read this application and state that the Issuance Fee -a 'j' LDMA PIC N - D -
8 above information is correct. I agree to comply with all County Investigation Fee /� 1 /
ordinances and State laws relating to building construction, Total Fe ✓ LDMA Perm. #
a and herebyauthorize representatives of this County to enter
��
upon he a(b�ove-m lerlfli�oned property for inspection purPo(se_s.
, 1�i A- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicanl•of Agent 'D'ale -