HomeMy Public PortalAbout6632 CLOVERLY AVE_Building__ � p:• �
WORKERS'COMPENSATION DECLARATION .�
I hereby affirm that. I have a certificate of 1jjfit`to.,s4'9
se' p�}� DP M D D O nn
insure, or a certificate,of;Workers'Compensation Insurance, /r'tl-LI L d CAU d O LI V F D -Au d Lod LI M V
0 or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES, BUILDING AND SAFETY
Policy No. Company f
Certified copy is'Fereby furnished.. FOR APPLICANT TO FILL IN ADDRESS&&:3ZI`71GC%D1�G J', r7' l
❑ Certified copy.is filed with'the county building inspec- BUILDING
tion•departrrient. LOCALITY ` pADDRESS �{� ter"
NEARE
Date Applicant CITY A Cil ZIP. CROSS ST.
Pa
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT 35 X,ql,5'O NOW ON LOT I MAP BOOK IPAGE PARCEL
(This section need be completed if.the permit is for one USE ZONE MAP
hundred dollars($100)or,less.) a TRACT / BLOCK LOT NO, NO,
GL�/ Y TEL. // jd� ` r I SPECIAL ?-
I certifyThat in the performance of the work for which this OWNER /� IGS s��,l N07 C7�r CONDITIONS A .
P �i, DISTRICT GROUP TYPE FIRE PRO SSED"BY
permit is issued, I shall not employ any person in any manner ADDRESS �Gyi2 '�/LCZ C/r�'G CON Tl- ZONE U
so as to become ubject to the Workers'Compensation Laws. _ fig
CITY mC C e/l ZIP._ v O
Date ApplicanT ARCHITECT OR TEL. STATISTICAL CLASSIFICATION APT. CONDO.
NOTICE. TO APPLICANT: If, after making this Certificate of ENGINEER �r/v '/&b�v NO. CLASS NO. � DWELL. UNITS LU
U
Exemption, .you should become .subject. To the Workers': - 9L
Compensation provisions of the.Labor Code, you mustforth- ADDRESS SEWER MAP N
with comply with.such provisions or this permit shall be •7 �71
deemed revoked. �t U� GW/TEL.��� 1+�3 w� BK. OPG, /-7 VALIDATION
CONTRACTOR NO. 3
LICENSED.CONTRACTORS DECLARATION LIC.
l hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS��.� ►� � NO ���� VALU7ATION
(commencing with Section.7000).of Division 3 of the Business and �N✓ta�Y�1L� LIC. $• r Professions.Code, and my license:is in full force and effect. CITY s-yN o CLASS C!C/
SQ. FT. NO.OF NO. OF CHECK 'L
D
License Number .321 Lic.Class SIZE STORIES FAMILIES ONE
.,. NEW $
Contract orKfidSWS '04-�IV Date ,
DESCRIPTION OF WORK A
H re'G% hl-IA114 01A Q, ADD,
lam exempt under Sec' ALTER ❑ FINAL %r
B&P.C. for this reason ;0AW r�d1� REPAIR DATE-
: F
USE OF FINAL
Date:' EXISTING BLDG. • DEMOL Q _
APPLICANT
Signature / r► +� TEL._ By
�f17 � �(i�✓ �_ NO.
PRINT
OWNER-BUILDER DECLARATION \
hereby affirm that I am exempt from the Contractors License
i
Law far the following reason (Section 7031..5, Business and .. ADDRESS. r..
9824A,.:
Professions Code):, PRESENT
ElBUILDING '0 0 0 °:° 1 '4
I, as owner of the property; or my employees with ADDRESS
wages as their sole:compensation;will do thework arid r
the structure isnot intended or offered for sale(Section LOCALITY 2,° ,1 99,`5 Q'`
7044, Business and Professions Code).. . MOVING, TEL.'
ElI, as owner of the property, am exclusively contracting `. CONTRACTOR NO. ° 0 1 �.5 cz�
with licensed contractors'to construct the'project (Sec- gDDRESS 2. 1 :-8 3
'tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST. .
CONSTRUCTION LENDING AGENCY SET BACK ' 'YARD HWY PROP. LINE •WIDTH D
I hereby affirm_thaf there is a construction lending agency for - FRONT
the performance of the work for which this-perm it is issued .P.L.
(Sec. 3097,Civ. C.).
'SIDE -
m
P.L..,
v Lender's.Name
.. - P.C.Fee`$'' a Permit Fee -
Le.nder's:Address
I certify that I'have read this application and state that the Issuance Fee'
above information is correct. I agree to`comply.with.all County Investigation Fee !'
g ordinances and State laws relating to building construction, Total Fee
v and hereby authorize representatives of this County to enter
upop the above-mentioned property for inspection purposes. ;
o p SEE REVERSE FOR EXPLANATORY LANGUAGE .
'Signature of Applicant or Agent Date ®s