HomeMy Public PortalAbout6006 CLOVERLY AVE_Building__ � WORKERS'COMPENSATION DECLARAT ON
` affcertificate haver certificate of uon In cra self APPLICATION FOR BUILDING PERMIT �
.insure, or a certificate of.'''JVorkers' Compensation Inseranr_e.;
or acertifiecl-opy thereof (Sec. 3800,1Lab. C.
:„. • COUNTY OF LOS ANGELES BUILDING.AND SAFETY
Policy No.. ' Company 1:1 Certified copy is hereby furnished. . ; FOR APPLICANT TO FILL fN BUILDING
ADDRESS (J OD 6
Certified copy is filed with the county building inspec- BUILDING LUV L
tion department:' ADDRESS
DateApplicant•.• CITY L� ie`• ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS'' NO: OF-BLDGS. NEAREST
"COMPENSATION INSURANCE SIZE OF LOT �� l�s NOW ON LOT CROSS ST. Q
(Thi's section need'not be completed if the'permit is for one ASSESSOR `-
-hundred dollars ($100),or less.) TRACT BLOCKK L'OT NO: MAP BOOK AGE PARCEL
CL
Pcertif that in the ( kQi TEL � ( ��j' US N MAP `'
y e performance of the'work for which this OWNER c i E j NO. �(f "�f�3 >_
ermit is issued, I shall'not employ any person in any anner d ' SPECIAL '
so as to become subject to the Workers'Coilnsat ri Laws. ADDRESS- $S3 �'`' `�. CONDITIONS
� _ _ O
CITY ZIP
Date �� ��2 Applicant ARCHITECT OR TEL&!7
NOTICE TO APPLICANT: If, after making this Certificate of ,,// DISTRICT GROUP TYPE FIRE _ PROC D BY
Exemption, you should become subject to the, Workers' ENGINEER 'Cl NO. s �/`( � (J� n CONST. ZONE (�
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Compensation provisions of the Labor Code, you must forth-
ADDRESS f �j�a+�
with comply with such provisions or this.permit shall be - - TEL. l -
$ STATISTICAL CLASSIFICATION :/ APT. C NDO.. Z
deemed,revoked, CONTRACTOR NO. L�3'�Y�� A/
LICENSED CONTRACTORS DECLARATION i � - CLASS NO off' DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ,6
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP J(` '
Professions Code, and my license is in full force and effect. CITY CLASS BK /— PG/�1 VALIDATION
SQ, FNO. OF _NO. OF CHECK
XM
License Number Lic.Class SIZE of STORIES FAMILIES ONE
VALUATION 3`7 3
Contractor Date DES PTION'OF WORK NEW /)JI
ADD ❑ $ (/(/ ,
❑ I am exempt under Sec.
ALTER ❑ SCrI S(l /2
B.&P.C. for this reason C � 0 REPAIR ❑ $ 11 [O r
Date: USE OF DEMOL ❑ l }� 3l-O
EXISTING BLDG.
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT) NO. _. 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
Professions Code): PRESENT B 7
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS 4 2 1A A
wages as.their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY ' # o. 0 0 0 0
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- 1•.-O 9 8 4.7 5
tion 7044, Business and Professions Code). ADDRESS x .
REQUIRED TOTAL SETBACK FROM I o - 984,7 5 0.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. UNE WIDTH _ '. ,
I hereby affirm that there is a construction lending agency for FRONT �. 1 2_$6
-the performance of the work for which this permit is issued P.I. - - -o
ll
3097, Civ. C.). SIDE t
P.LrM
Lender's Name
o - LDMA Ref_. #',• _
Lender's Address
P.C. Fee$ Permit Fee t
I certify that L have read this application.and state that the. _ Issuance Fee tJ (J ll LDMA P/C# 'Y -
a above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee .� 15
LDMA Perm. #
and hereby authorize representatives of this County to enter
upon a abov ment oned property 4or inspection purposes.
a 1 t _13-46 SEE REVERSE FOR EXPLANATORY LANGUAGE
- -Signature of App icant-or Agent - Date
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