HomeMy Public PortalAbout5806 CLOVERLY AVE_Building__ ° RKERS COMPENSATION DECLARATION
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e ent to
nsvre a cerhf cane of WorkersriCompensat oficate of n Insuran elf APPLICATION FOR- WILDING PERMIT
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or o certified copy ther of S 3 00 Lab C ) / r
�� D LLQ-l �' - COUNT,If OF LOS ANGELES" BUILDING ND SAFETY
Policy Na 0;69_ om1 y 'V7V
BUILDING
Certified,copy is hereby furnished -FOR FPLIC NT\TO.FILL IN 4 ADDRESS 04K uo-e�
Certified copy is filed with the county,building inspec- BUILDINGv "
77
tion department /r,pp T „yy ADDRESS S�dsan" 'dam
, /tL,/ '°Yc(/ �N `c' 1 VOl� Y 1 LOCALITY 4r
� GYM _ 9
Date 7-DTS Applicant^ CITY G ZIP >
CERTIFICATE OF EXEMPTION FROM WORKERS ° ,•-'NO OF BLDGS,`' NEAREST
COMPENSATION INSURANCE SIZE OF LOT L O U)C I�TS NOW ON LOT �J CROSS ST
(This section need not be completed if the permit is for oneASSESSOR + tE
hundred dollars ($100)or less ) , TRACT S BLOCK LOT NOOIr+ MAP BOOK PAGE PARCEL
OWNER 0 160—Oj USE ZONE MAP
I certify that in the erformance of the-work'for which this �J ;{ J V
permit is issued, I shall not employ any person in`any manner �B —J SPECIAL , 5k1
so as to become subject to the Workers'Compensation Laws ADDRESS _ q CONDITIONS O
J p
. „f �, I , CITY ,t 3 _ ZIP �
Date ApplicanP"' ---1' ""•
NOTICE TO APPLICANT If, after"making this-,Certificate of ARCHITECT TEL ZI 3 DISTRICT GROUP TYPE FIRE PR SSED BY: 0
ENGINEER" T NO -1 CONST ZONE (—
Exemption you should become subject to the Workers' - / Sa. 5 U
Compensation provisions of the Labor Code, you must forth ADDRESS Z{p V 1J�( �Tpv LLJ
with comply with ,such_provisions or this permit shall be CL
deemed revoked TEL STATISTICAL CLASSIFICATION APT CONDO (q,
i CONTRACTOR •.V N �' 2 �6 /13� Z
r ' LICENSED CONTRACTORS DECLARATION; r LIC CLASS NO [/ DWELL UNITS
I'hereby affirm that I am licensed under provisions of Chapter 9" ADDRESS NO `fes
(commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP
Professions Code and my-hcense is in full force and effect CITY 0j417A&Zr CIASS . 'tBK L PG 1�� VALIDATION
_ xn SQ FT O O T W NO OF 4- CHECK
License Number,' �Lic Class SIZE _ 2�� 5 RIES FAMILIES T ONE
_ VALU TION O (%
' o Date jd �� $ DESCRIPTION OF WORK
ContractoW srp Z ' NEW $ /7 (!
O7y06 Ur a 1
r ( _ ADD ❑
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❑ C�o�►Das �v C ❑ ® �l� 9, y 7 2 _
I am exempt under Sec
ALTER ,
❑ .� '
ByBP C for this`reason REPAIR
Date � 4
USE OF ❑ 7L// l7J(/
EXISTING BLDG t DEMOL
A Signature APPLICANTSTFi V �JT��TEL
NO FINAL'
OWNER-BUILDER DECLARATION DATE ��6
I hereby affirm that I am exempt from tKe Contractor s License ADDRESS�-(�1r'1���s'CJf-� �.� s F
Law for the,following reason (Section 7031 5, Business and
rJ
Professions Code), PRESENT Y -
BUILDING
1, 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 ® Yr
7044, Business and Professions Code) MOVING TEL
1, as owner of the property, am exclusively contracting CONTRACTOR NO
-- with licensed contractors to construct the project (Sec-
tion 7044,_Business and Professions Code)'` ADDRESS t s
REQUIRED TOTAL SETBACK '
CONSTRUCTION LENDING'AGENCY r` SET BACK YARD HWY `PROP LINE ' WIDTH _ :`;, 'd r °e, # '®'� t`
I herebyaffirm that there is a construction lending agency for
9 9 Y FRONT j, ti ;�4 ,� y`0 ti r"»,C` �( 2 2 8'0,:7 5
the performance of'the work for which this permit is issued P L r MAY ` z4` 2 2'8 Q,7,5 c=� y '
(Sec 3097, Civ C ) SIDE _ ;i f� t
P L 5 t n�o, 1'1`y,,- ± vM,, t, aw w`'+'SIA 0,0 i 8 8 •r
\, ,
Lender's Name - ti
w ^
PC Fee$
LDMA Ref # ;.
Permit Fee
Lender s Address
I certify that,I have read this application,and state that theIssuance Fee ( Q LDMA P/C#
above information is correct I agree to comply with all County . Investigation Fee y �( '-77
0 ordinances and State laws relating to building construction, - Total Fee 6./.,t�- LDMA Perm #
and hereby authorize representatives of this County to enter
g - upon the above-mentioned property for inspection purposes
SEE REVERSE FOR-EXPLANATORY LANGUAGE A
Signature,of Appl,can or Afient e s r <
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