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HomeMy Public PortalAbout5453 CLOVERLY AVE_Building__ WORKERS' COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 1� Policy No. Company BUILDING Certified copy is hereby furnished. c/FOR?APPLICANT TO FILL IN ADDRESS El Certified copy is filed with the county building inspec- ADDBUILDING RESS ( <--> E� ` E. tion department. �fvDate Applicant CITY e/ & ZIP / 756 LOCALITY >• :II� 6 t' NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. < COMPENSATION INSURANCE ASSESSOR f)��� (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK �l PAGE C6z PARCEL hundred dollars ($100) or less.) I_ TEL. OWNER ' NO. USE ZONE MAP I certify that in the performance of the work for which this NO. 7 2 �S permit is issued, I shall not employ any person in any manner ADDRESS L SPECIAL d CONDITIONS so as to become subject to the Workers' Compensation Laws. r O CITY ZIP U Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER V NO. CONS ONE U Exemption, you should become subject to the Workers' /f p Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTOR / o NO. Z LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO.r� DWELL. UNITS — 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS J Q I r• NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP + � CLASS and Professions Code,and my license is in full force and effect. CITY `P f _ BK. 2D PG.7 / VALIDATION SQ. FT/yt O' O. OF NO. OF CHECK License Number Lic. Class SIZE !�Q TORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW $ t (�/(//�� O / ADD El �" � � ❑I am exempt under Sec. � �� L /1dr+ tai ALTER ❑ B.BP.C. for this reason ` REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL FINAL OWNER-BUILDER DECLARATION (PRINT) NO. A 2 DATE — I" I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL r Professions Code): PRESENT By 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. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS 'on 7044, Business and Professions Code.) REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK 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 P.L. Lender's Name / DMA Ref. # P.C. Fee$ Permit Fee "7 Id , 3 Lender's Address 0 1 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 C/ R ordinances and State laws relating to building construction, Total Fee --3. / LDMA Perm. # a and herebauthori epres y s of this County to enter n t bov for inspection purP9ses. a _.hat l �) SEE REVERSE FOR EXPLANATORY LANGUAGE Signature f Ap fico t o nI ate v L yy \ e WbRKERS' COMPENSATION DECLARATION nsrelit'affirm that I have certificate of consent to self insure, APPLICATION .f aR BUILDING PERMIT ` nsure, or a�certificate of Workers' Compensation Insurance, _�. ora certified copy thereof (Sec. 3800, Lab. C.) CCOUNFY OF LOSQNGE .S BUILDING AND SAFETY j N Policy No. Company ( a i BUILDING �f/�J ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS J ❑ Certified copy is filed with the county building inspec- BUILDING ADDRESS tion department. .-Fr•��,p CITY 6—MI IL ��r r ZIP LOCALITY C Date ' Applicant NO. OF BLDGS. ° CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT bC1fi I2-Z7 NOW ON LOT NEAREST CRASS ST. A''I W ES 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 ($100) or less.) TEL. / OWNER IA SAVN-'a ^ �IAn'1/N NO. Z�� USE ZONE O. I certify that in the performance of the work for which this / SPECIAL a permit is issued, I shall not employ any person in any manner ADDRESS 51-5J CONDITIONS so as to become subject to the Workers' Compensation Laws. �i j O700 U CITY ( ZIP Date Applicant ARCHITECT OR A. .T E�L. g DISTRICT GROUP TYPE FIRE PROCESSED BY tY NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER / A. MoN�90L 3 "1&6i O CONST. �NE U Exemption, you should become subject to the Workers' ADDRESS 1IjS 7 rQ ii � ,r�$ �a f ov�YOvl w ��O _ /� 0 Gd�eL� "-t Compensation provisions of the Labor Code, you must forth- T°� V a- with comply with such provisions or this permit shall be __ TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR -- _ NO. O Z LICENSED CONTRACTORS DECLARATION 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 Divi ion'3 of the Business LIC. and Professions Code,and my licenseJ's"in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. p O NO. OF r NO. OF r CHECK License Number Lic. Class SIZE 7J STORIES FAMILIES ONE elf_ wwPutms. ID Contractor Date DESCRIPTION OF WORK C/A�IDE IP-GOf(A911V t•7 NEW a �Q o© ^ NtW A 9,1911 D/V NE+� �LL/!/VG�f ADD 16 - ALTER ( J ❑I am exempt under Sec. p��� ❑ lie/ ,nav 7vB.&P.C. for this reason l C3m REPAIR ❑ $ Date: USE GING BLDG. �� DEMOL ❑ APPLICANT / /�� TEL. (�, Signature )_ FINAL ° OWNER-BUILDER DECLARATION (PRINT) IQX /yr0✓!TZ 17i'Q NO -4s T b/�Q jp f/ /�' 0 DATE J J I hereby affirm that I am exempt from the Contractor's License ADDRESS W-7tl t`T� V fK �V�VO�w� Law for the following reason (Section 7031.5, Business and FINAL Professions Code): PRESENT ;' BY s AtCg'os ® I, as owner of The property, or my employees withBUILDING ADDRESS 48.'_t 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. ?, CONTRACTOR NO. °"' A E] 1, as owner of the property, am exclusively contracting r•CCT.T with licensed contractors to construct the project (Sec- F.Investigation +� 7 tion 7044, Business and Professions Code.) F u1b°I_L TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY YARD HWY PROP. LINE WIDTH ; T t EMS I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued TOTAL !��—° (Sec. 3097, Civ. C.). p CHECK 36".7 s Lender's Name �;�aE hl Permit Fee LDMA Ref. # 3 Lender's Address o I certify that I have read this application and state that the Issuance Fee Z fr°. LDMA P/C# , � ����� • j f,1 above information is correct. I agree to comply with all County n'Fee �7 i AM 6 Ord inanc and State laws relating tobuilding construction, Total Fee 6, LDMA Perm. # 5274 1 AM v:44 a and he thorize representatives of this County to enter upon ve-mentioned property for inspection purposes. o \]� SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Appli6&t or Agent Date