HomeMy Public PortalAbout4927 CLOVERLY AVE_Building__ .W6RKERS' COMPENSATION DECLARATION — ti
• 4.he•_by affirm that I have a'certificate.of consent to self
insure, or a certificate of Workers' Compensation Insurance, A P P L'I CAT tO IVB FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, b C.) t COUNTY OF LOS ANGELES BUILDING AND SAFETY
PoIieyle_I 'F'�IpCompany
❑ Certified co is hereby furnished. e,r 11-1—%2- FOR APPLICANT TO FILL IN BUILDING f� r,
copy Y ADDRESS 4
Certified copy is filed with ih uilding inspec- BUILDING
tion department.
ADDRESS L} L
Dat / Applican CITY ZIP LOCALITY L
ccQQ NO. OF BLDGS. NEAREST
CER IFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT c�C.� NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR.
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BO PAGE a PARCEL
hundred dollars ($100) or less.) TEL.
OWNER NO. USE ZONE MAP
NO.
I certify that,in the performance of the work for which this 11�
permit is issued, I shall not employ any person in any manner + ADDRESS SPECIAL d
CONDITIONS
so as to become subject to the Workers' Compensation Laws. 10
t� CITY ZIP
Date Applicant `) AR ECT TEL. FIRE
NOTICE TO APPLICANT: If, after making this Certificate of G NEORS NO. DISTRICT GROUP TYPE PROCESSED BY
CONST. ONE
Exemption, you should become subject to the Workers' Q �f V
Compensation provisions of the Labor Code, you must forth- ADDRESe-o- 5i-,3E> �DO pW
with comply with such provisions or this permit shall be TEL. A STATISTICAL CLASSIFICATION APTCONDO. Z
. N
deemed revoked. CONTRACTO - NO.JW-yV/O ,,ma�yy ��
LICENSED CONTRACTORS DECLARATION ADDRE0440' � LICNo' CLASS NO.�DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business LIC. y SEWER MAP
and Professions Code,and my license is in full force and effect. CITY �t4foj� CLASS BK. PG. VALIDATION
�ro /jC� �, SQ. F NO. OF NO. OF CHECK
License Number 55 De 1 Lic.-Classes` SIZE STORIES FAMILIES ONE VALUATION
1 II q� DESCRIPTION OF WORK NEW t •.
Contracto Date
S. ..D� ADD ,.=t :
El __..
❑I am exempt under Sec. 01111.
ALTER ❑ _� �t
BAP.C. for this reason REPAIR ❑ $ lq"�, e
G'D� 4v
Date: USE OF -S::': ;7 _
EXISTING BLDG. DEMOL ❑ 4r F,: iv(`±
Signature APPLICANT TEL. »•i•_`•`-
(PRINT) NO. FINAL Z s : •_ ar:-
OWNER-BUILDER DECLARATION - DATE Z� C t
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 ByIjF
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. pop. ,;': i-,• �__ v
CONTRACTOR❑ NO.I, as owner of the property, am exclusively contracting - ° _. t ,.k•
with licensed contractors to construct the project (Sec- ADDRESS �-
tion 7044, Business and Profess ions'Code.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE 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
i
P.L.
Lender's Name '
Permit Fee >e
P C. Fee$ /�Q •�a LDMA Ref. #
Lender's Address
o I certify that I have read this application and state that the 00
Issuance Fee 1 • LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee
R ordinances pRd State laws relating to building construction, Total Fee / / + LDMA Perm. #
a and a horize representatives of this County to enter
upo o e-mentioned property for inspection p rp ses.
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent D to