HomeMy Public PortalAbout6043 CLOVERLY AVE_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION F I L D I N G PERMIT
insure, or a certificate of Workers' Compensation Insurance, �
or a certified cop thereof�(S(e�c. 3800, Lab. C. 1!� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N0. rrr any
❑ fV
BUILDING
ertified copy is hereby furnished. /d/�/����1 FOR APPLICANT TO FILL IN ADDRESS �Q 3
Certified copy is filed with the county building inspec- BUILDING• /
tion department. ADDRESS
�' CITY' I LOCALITY 9
SPECIAL
Date�'_�= Applica NO. OF BL GS. 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 TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) /� TEL' SE ZONE MAP /
OWNER /�-� NO. NO. <5—O /`/off [o
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS' \Y �_� CONDITIONS CL
so as to become subject to the Workers' Compensation Law's. 0
CITY ZIP
Date Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE �FIRE PROCESSED BY De
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ONE
Exemption, you should become subject to the Workers' p ,/
Compensation provisions of the Labor Code, you must forth- ADDRESS , e 3 Y a
with comply with such provisions or,this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. to
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deemed revoked. CONTR � f/( N q �
LICENSED CONTRACTORS DECLARATION / / r7� CLASS NO.CL—DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 0 (p 6
SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC. ,
and Professions Code,and my license s in full force and a ct. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number bc. Class SIZE I STORIES FAMILIES ONE
C0�(1�j�(�/�'�^ VALUATION
,9 4 C Lc _:y ' DESCRIPTION OF WORK W�l NEW ❑
❑I am exempt under Sec. ® Ink)� ADD ❑ S ►
LTER 103B.&P.C. for this reason vv V EPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT \ TEL. L�
g OWNER-BUILDER DECLARATION (PRINT). �1�� NO. / FINAL
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL P/7
Professions Code): PRESENT BY,
� ' � ;• �.
BUILDING' t
❑ I, as owner of the property, or my employees with ADDRESS v _
wages as their sole compensation,will do the work and LOCALITY -:7 -x
the structure is not intended or offered for sale(Section
7044, Business and Professions Code.) MOVING TEL.' ' i ,'_;•,
❑ I, as owner of the property, am exclusively contractistg CONTRACTOR NO. _
with licensed contractors to'construct the project (Sec-
J
tion 7044, Business and Professions Code.) ADDRESS i HE
,•
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY. SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lendingagency for 'FRONT ;.:IMS.E
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
LDMA Ref. # - -- :•::., -_..
Lender's Address P.'C. Fee$ Permit Fee %� �� _ _ _ r;ii=•
o I certify that I have read this application and state that the Issuance Fee C5?7 LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee
R ordinances and State laws relating to building construction, Total Fee // �i LDMA Perm. #
a and hereby authorize rep,r ntatives of this County to nter
upon The v m t on pro eaf o inspection pu oses
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent ate