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HomeMy Public PortalAbout10640 DAINES DR_Building__ WORKERS' COMPENSATION DECLARATION -herewy,. affirm➢hat I have r certificate of cion Insurance,self. ������`��®'�,n ®� �n n�n ®� n� ������ . iosu;e; or o certificate of Workers'Compensation Insurance, (�—J u uu��' L�JJ L.L N or a certified copy tKn;4of (Sec. 3800, lab. C.) ❑oCOUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company _ Certified copy is hereby furnished. FOR APPLICANT TO FILL 1N BUILDING ' 5 ADDRESS Certified copy is tiled with the county building inspec- BUILDING ,�LrLL .1 lion department. ADDRESS �46 L IN� Dare Applicant CITY G Gi (l•� ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ��( � U NOW ON I CROSS ST. COMPENSATION .INSURANCE /—• !"f (This section need not be completed if the permit is for oneR ASSESSOR - hundred dollars ($100)or less.) TRACT 6 BLOCK LOT'NO.' MAP BOOK PAGE PARCEL TEL. I J USE ZONE 'MAP .-r I certify that in the performance of the work for which this OWNER � NO. NO, lql ;Z permit is issued, I shall not employ any person in any manner [[//�� ,�ff / SPECIAL so as to become subject to the Workers'Compensation Laws. - ADDRESS V07V N ! CONDITIONS O Dote s L+" Applicant ' t CITY � f7 ZIP /p© It NOTICE TO APPLICANT: If, after making this Ce ific to of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers- ENGINEER NO. CONST. ZONE V Compensation provisions of the Labor Code, you must forth- ADDRESS �//QV ` W with comply with such provisions or this permit shall be _ d deemed revoked. '�/ TEL - STATISTICAL CLASSIFICATION APT. CONDO. C/)CONTRACTOR W� NO. n Z LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and _ LIC SEWERMAP Professions Code,.and my license is in full force and effect. CITY CLASS BK. ` PG. VALIDATION • SQ. FT /� NO.OF - NO. OF / CHECK License Number Lic.Class SIZE (j STORIES FAMILIES 1 ONE - VAll1AJl Contractor Date DESCRIPTION OF WORK Q {L NEW ❑ $ ADD 54 I am exempt under Sec. 206 ALTER ❑ e `43 -i`914,.0 A B.BP.C. for this reason a REPAIR ❑ $ Date: EXISTUSE ING {�.e ING BLDG. a.�I p� IL^L DEMOL ❑ a •. 1 . 55845 Signature APPLICANT - 'TEL FINAL e • OWNER-BUILDER DECLARATION PRINT -NO. DATE 5 5 a 4 5 x 6 I hereby affirm that.I am exempt from the Contractor's License 0 3. 107-88 Low for the following reason (Section 7031.5, Business and ADDRESS FINAL _Pr9jessions Code): PRESENT By I, as owner of the property, or my employees with BUILDINGADDRESS wages as their sole compensation,will do the work and -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. withlicensed contractors to construct the project (Sec- gDDRE55 :995& 5A tion 7044, Business and Professions Code). - REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY - YARD HWY - 1 SET BACK PROP. LINE ' WIDTH �},. •,• . • hereby affirm that there is a construction lending agency for FRONT' - ,I.• 667.5 0 the performance of the work for which this permit is issued . P,1. . . (Sec 3097, Civ. C.). SIDE 6 b 7.5 0 P.L. Lender's Name ' ' -t 0 5 0 b,=8 8 LDMA Ref. If m Lender's Address - P.C. Fee E 1_S� 4�111� Permit Pe - I certify that I have read.This application and stole that the Issuance Fee V SV ..LDMA.P/C N D o above information is correct. agree to comply with all County Investigation Fee' �'` q ordinances and State lows relating to building construction, Total Fee \7 LDMA Perm. N a and hereby authorize representatives of this County to enter �• 9 upon the above-mentioned property for inspection purposes. �O r� SEE REVERSE FOR EXPLANATORY LANGUAGE \� 'V ` r Q �•r , t� Si aWra of pint orA am - pole - '-+ice \ `y,,