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HomeMy Public PortalAbout5414 CLOVERLY AVE_Building__ f� WORKERS COMPENSATION DECLARATION '+ r:I hereby affirm that I have certificate of consent to self A P P L I CATION_F O'R BUILDING P E RM I T insure, or a certificate of Workers' Compensation Insurance, �_' ' or a certified copy thereof (Sec 3800, Lab C ) COUNTY-OF LOS ANGELES BUILDING AND SAFETY' ` t Policy No Company -T ❑ Certified co is hereb furnished t, FOR APPLICANT TO FILL IN BUILDING L V � copy y ADDRESS ❑ -Certified copy is filed with the county building inspec- BUILDING ° tion department ^ ADDRESS Date Applicant CITY /T ZIP LOCALITY pp NO OF BLDGS _ _ NEAREST - - CERTIFICATE OF EXEMPTION FROM WORKERS" SIZE OF LOT NOW ON LOT CROSS ST COMPENSATION INSURANCE ASSESSOR_ (This section need not be completed if the permit is for one c- ^ TRACT BLOCK LOT M: i' MAP BOOK t. PAGE PARCEL (hundred dollars ($100) or less ) `' 0 T TEL Qd US ONE OP OWNER % I certify that in the performance of the work for which this ,/ /^r . A C r ' - x SPECIAL permit is issued;I shall not employ any person in any manner ADDRESS "'/ - L�.[J��� V F ^�-� CONDITIONS so as to become subject to the Workers Compensation Laws Ir l u7� °._ , 0 a _ CITY-7_J5-,l1"1 rppL6` ZIP DD(J Date Applicant - ARCHITECT OR TEL NOTICE TO APPLICANT, If,'after making this Certificate,of ENGINEER , NO - - DISTRICT GR UP TYPE �� FIRE OCESSEp BY O CONST 1 ► ' ZONE Jl7 /1 U Exemption, you should become subject to the Workers w Compensation provisions,of The Labor Code, you must forth- ADDRESS K• "3 a 3 N with comply with such provisions or this per`mit,sholl be TEL STATISTICAL CLASSIFICATION APT CONDO Z` deemed revoked, 14CONTRACTOR NO — LICENSED CONTRACTORS,DECLARATION Z _ LIC CLASS NO DWELL UNITS I hereby affirm that I am licensed under,provisions of Chapter 9 ADDRESS NO SEWER MAP (commencing with Section 7000)of Division 3 of the Business g LIC - and Professions Code,and my license is in full force and effect CITY CLAS BK PG VALIDATION SQ FT NO OF NO OF CHECK License Number i Lic Class SIZE STORIES FAMILIES ONE VALUAT Contractor Date DESCRIPTION OF WORK r NEW ❑, ,;0� 4,a ^ D } - ADD ' ❑ 1 ► ❑I am exempt under Sec - - - . , ALTER _ - B&P C for this reason ' y `�■ © REPAIR ❑ $ _ USE OF Date EXISTING BLDG DEMOL ❑' ° Signature _ APPLICANT ,t TEL - - FINAL OWNER-BUILDER DECLARATION (PRINT) NO 1+ DATE I hereby affirm that I am exempt from the Contractor's License Law for the following`reason (Section 7031 5, Business and , ADDRESS FIN / AC(``7 Professions Code) - PRESENT- - r r `- j Y BUILDING + ~� f aa` Y ❑ I, as owner of The property, or my employees with ADDRESS " - t+ wages as their sole compensation,will do the work and ' "" - _ �.�, 1 �7 ��'i'' the structure is not intended or offered for sale(Section LOCALITY f 'Y 1 IT t, f 7044, Business and ProfessionsiCode') _ � � MOVING - 1 TEL - � � - � ' ' CONTRACTOR NO , " TOTAL ' �G-9 ��+-1 ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ^` ruC 4� �� y ADDRESS tflG � ■Vv tion 704, Business and Professions Code ) r' REQUIRED TOTAL SETBACK FROM 'EXIST r'r CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WIDTH - - CHANE t - ■`'LI 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 ) = �-y�'y�{ SIDE Y t -F ° 'VA w 000()-WO J X 1,,187 Lender's Name` 5952 j "�PMLI■ai LDMA Ref # P C'Fee$ Permit Fee Lender's Address _ f o I certify that I have read this application and state that the Issuance Fee 5°O LDMA P/C# ► 8 above information is correct I agree to comply with all County Investigation Fee _ _• t ordinances and State laws relating to building construction, Total Fee LDMA Perm # and'here)y authorize repres tives of this County To enter N r upon,IF ghove-m tioned perty f spection purposes _ M ¢ SEE REVERSE FOR EXPLANATORY LANGUAGE Sig'ature o Applicant or Agent Date - i , t