HomeMy Public PortalAbout9662 CRAIGLEE ST_Building_8/5/1988_addition of 3 ba, 3bdrm, fam rm, kitchen WORKERS' COMPENSf ION DECLARATION
j r 'affirm that I have a certificate of consent;to self O O O D O
insure, or a certificate of Workers' Compensation Insurance, [111 �j y ���,0 IJV " Lj,,`O �J M D Dl C� p `
or certified copy thereof (Sec. 3800, Lab. C.)
COUNTY,OF•LOS ANGELES BUILDING AND SAFETY
Policy No. Company ti
Certified copy is❑ ' hereby.+furnished. . ♦ BUILDING
\•` iAC , LL,I
ADDRESS
Certified copy is filed with the county building inspec- �eUILDING
tion department. ADDRESS
Date Applicant- CITY 6*1P. O LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. C BLD T NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if-The permit is for one TRACT BLOCK' LOT NO. ASSESSOR
hundred dollars.($100)or less.) -` MAP BOOK PAGE PARCEL
TEL. USE NE MAP
I certify !hat"in the performance of the,work for which this OWNER ' SaIA, NO. T�x�/� NO. _
Permit is issued, I"shall'not employ any person in any manner IK ` SPECIAL ]
so as to become subject to the Workers'Compensation Laws. ADDRESS 6&
nn VV" CONDITIONS O
Date / — R Applican,.�RJ/ / A.
CITY G 6&ZIP -l' �O U;
_ ARCHITECT OR i, _ TgL� "
NOTICE TO APPLICANT: If, -after making this�Certificaie of ENGINEER Y Ghp6a. `1qj gl•j4. DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject To the Workers' CONST. Z NE F-i
Compensation revisions of the Labor'Code, you must forth- V I
P P Y ADDRESS QLsa,I ,N'a U W.
with comply: with, such provisions or. this permit shall be p_,'6 .
deemed revoked. =" TEL. STATISTICAL CLASSIFI ATION APT. DO. ;N
CONTRACTOR NO. Z.
LICENSED CONTRACTORS DECLARATION LIC ' CLASS NO. r DWELL. UNITS
I hereby affirm that 1 am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and1/ LIC SEWER MAP.
Professions Code, and my license is in'full force and effect. CITYAAA, 16,4V, CLASSBK _ VALIDATION
SQ. FT) , N�9�O NO. OF- CHECK
License Number Lic.Class SIZE b STa & FAMILIES ONE
VALUAT N
Contractor Date DESCRIPTION-OF WORK -rJC>K NEW ❑ $.. '
Elam exempt under Sec.
%3 �rn5 d0 �"�S B. ADD 203 6 7'A
i ALTER 2 /�
B.BP.C. for this reason V'VV+ 43 �1` G�Y` 64V"J'al-� t REPAIR ❑ $ t add ,
�$ 0 0 0 e.�3
`Date: ' i" C L W� �"hn DEMOL / I ® 6 9 8,0 7
EXISTING BLDG. ❑
Signature APPLICANT pt e, TEL. y n�)I to FINAL � P•0 6 9�0'7S
OWNER-BUILDER DECLARATION PRINT V NO. 1 D`'(`7(/ FINAL,-- �' 0 8.0'5_8'8
I.hereby affirm that Gam exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS QIii FINAL
Professions Code):
PRESENT BY '
;. BUILDING
I, as owner.of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and D
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING "' TEL.
I, as owner of the property,.am exclusively contracting CONTRACTOR NO.
t t7
with licensed contractors To construct the-project (Sec-
ADDRESS
tion 7044, Business and,Professions Code). /5. s-
r u REQUIRED. TOTAL SETBACK FROM EXIST. I
CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINEWIDTH
I hereby aff . FRONT L
the performance of the work for which this permit is issued P.L. 2?A
(Sec. 3097, Civ. C.). - SIDE r
-lender's Name _
m P.C. Fee$ Permit Fee (� i S LDMA Ref. n I'=�.9"1':2.7 5
Lender's Address _
ale 91275U'
g 1-certify that I have read this application and.state that the Issuance Fee ( Oc�] v LDMA P/C'# D
above information is correct..)-agree to comply with all County Investigation Fee 12 Q 5 8 8
o ordinances and State laws relating to,building construction, Total Fee LDMA Perm. #
and hereby authorize representatives of this County to enter, ,y t
m upon the above-mentioned property for inspection purposes.
c ' J 3�
� -�-��`� SEE REVERSE FOR EXPLANATORY LANGUAGESignature of,Ap licant or Agent - .Dote