HomeMy Public PortalAbout6037 CLOVERLY AVE_Building__ ° WORKERS' COMPENSATION DECLARATION
of co.nsent to
insure,oraaffirm
certif certificate of Wo ke srlificate Compensat on Insur6n elf - A P PIL FOR WILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) rOUN*Y OF LOS ANGELES BUILDING AND SAFETY
Policy No. 13(612)Y'91 Company5"'(Par- Fw,o V
BUILDING
❑ Certified copy is hereby furnished., FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed wit the cou ty b ilding inspec- BUILDING j_ O 3^7" �rw`9,LY
tion department. ADDRESS`` �p /
Dare �' a '9L Applicant CITY 1 C-MP E JTy ZIP LOCALITY
PP NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTI N FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION SURANCE ASSESSOR �3D /
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL�(D
hundred dollars ($100) or less.) TEL.NO
OWNER � �E - �5 U . USE ZONE MAP
I certify that in the performance of the work for which this NO.
Z SPECIAL h >_permit is issued, I shall not employ any.person in any manner ADDRESS 0J C1.;OVE:9L_Y CONDITIONS Q
so as to become subject to the Workers'Compensation Laws. U
CITY S = 1MO Cv, ZIP
Date Applicant - ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER JIL { E NO. Q9-SS�SO
D 11 ii i �7 �/ CONST. • ZONE U
Exemption, you should become subject to the Workers' ADDRESS 11 Z V E�/"C� %i.0 t7 �C/(J Ge l ow.
Compensation provisions of the Labor Code, you must forth- '
with comply with such provisions or this permit shall beTEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
revoked,voked. CONTRACTOR • NO. 446-1640 —
LICENSED CONTRACTORS DECLARATION. LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS .30 9T J� NO. �5 75 �D SEWER MAP
(commencing with Section 7000)of Diyision 3 of the Business LIC. �]
and Professions Code,and my license is in full force and effect. CITY rC A CLASS l7 BK PG VALIDATION
�^ (� SQ. FT. NO. OF NO. OF F CHECK �ty'
License Number COS 1 S 8o Lic. Class SIZE 1 O STORIES / FAMILIES f ONE
', I `- n ADD VALUATION ACCT.AV
Contractor _
11JeS+ Cr,a-mak �-Albate e' S' `l eo DESCRIPTION OF WORK �� G NEW ❑ $ 19,000
3303 9910 'i
A `
❑ �I am exempt under Sec. cj IwN4 ALTER ❑ , 1 ITEMS
B.BP.C. for reaso C�pC u x ' �XA L�
REPAIR ❑ $ TOTAL 996 - 62
Date: USE OF 5� ►+JJ.�¢
EXISTING BLDG. S.>}•K• DEMOL ❑ CHECK 996 e 622
Signature APPLICANT TEL. FINAL 3
(PRINT) �OC: phi NO. (o'ZOND /J .00
O�ER-BUILDER DECLARATION ) i ` DATE I �--7"�( �'�� �E
I hereby affirm tha�I am exempt from the Contractor's License ADDRESS 3033 Jr 9-ih 2 P dt FINAL j
Law for the following reason (Section 7031.5, Business and
Professions Code): IV-. PRESENT BY �-�01 6/ %3/96
NIT, BUILDING
El I, as owner of the property, or my employees with ADDRESS a•
wages as their sole compensation,will do the-work and LOCALITY 1 '`
the structure is not intended or offered for sale(Section - , 1 ITEi�?
7044, Business and Professions Code.) MOVING TEL.
CONTRACTOR NO.
❑ I, as owner of the property, am exclusively contracting TOTAL 7 i
with licensed contractors to construct the project (Sec- tt rV 1' 11°�
ADDRESS C."HECK 111064
tion 7044„Business and Professions Code.) - j i �
REQUIRED TOTAL SETBACK FROM.. ' EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH CHANGE aA0
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. 0000-0001 6/25/9
Lender's Name / i 1 M {!9
t
o �/.// !� LDMA Ref. # (10b 1 I t 1=
m P.C. Fee$ /�' Permit Fee
Lender's Address
o I certify that I have read this application and state that the Issuance Fee y a �`�� IPLDMA P/C#
0
8 above information is correct. I agree to comply with all County Investigation Fee / �C�
g rdinances and State laws relating to building construction, Total Fees .:P �� / LDMA Perm. #
a d her Ementiize representatives of this County to enter
u n th onedproperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date