HomeMy Public PortalAbout10924 DAINES DR_Building__ WORKERS'COMPENSATION DECLARATION ,1T�v �,{
hereby'affirm that I have r certificate of cors Ins to self• n PP�1 �C./A� lMN IC�6R 9 P D MO FERMPT
insure, ord certificate of Workers' Compensation Insurance, (y=J Lrl (rJ u I1J�Jl nil V LLQ, Il CI 0CY❑
or a certified copy
/thereof (Sec. 3 DO, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No ��o�pony -
❑ Certified copy is hereby furnished. °• FOR APPLICANT TO FILL IN- ADDRREESSSS y -
ADD
ING
Certified copy isfiled with the county building inspec- BUILDING 'O /
tion eporl ent. ADDRESSq1iI LOCALITY '--..:'��s
NEAREST-
' Date plicant CITY ZIP CROSS S7. - -.
. C TIF ATE OF EXEMPTION FROM O ERS' - - - - :OF BLDGS. - ASSESSOR •
COMPENSATION INSURANC SIZE OF LOT N W ON LOT MAP BOOK PAGE PARCEL
--_(This section.need.not-betmmpleted.if Lthe'permii.is•for one -- -= = -- -
BE
- -- - _ MA
_— _-
USE P --..
hundred dollars ($100)or'less:) - - IRAQ" BLOCK LOT NO. NO
- - TEL. ��/ SPECIAL } -
Ir
certify that in the performance of'the work for which.this OWNER NOI /� CONDITIONS _ _ 1
- DISTRICT. GROUP TYPE - FIRE PR SSED BV O
so as t is issued, I shall not employ any person in anon Laws. ADDRESS C� CONST. ZONE U
so as to become subject to the Workers'Compensation Laws. i `
Date Applicant - CITY ZIP STATISTICAL CIASSI ICATION APT. CONDO. FO
NOTICE TO APPLICANT: If, after making this.Certificate of ARCHITECT I TEL. ,,�� �
ENGINEER NO. CL ASS NO.�LDWELL..UNI75 IN
Exemption, you should become subject to the Workers' 6
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP - W
With comply with such provisions or this permit shall be - Z
TEL /� VALIDATION
�'"deemed revoked. CONTRACTOR NO. BK. SPG,' �„•
LICENSED CONTRACTORS DECLARATION LIC.
I hereby off irm that I am licensed under provisions of Chapter 9 ADDRESS (Z C4NO. VA DATION C
• (commencing with Section 7000)of Division 3 of the Business and C LIC
Professions Code, and my license is in full force and effect. CITY J. CLASS ➢ $ (J D .
SQ. FT. NO.OF NO. OF CHECK
License Number_. Lit.Class SIZE STORIES I FAMILIES I ONE - .. .
Contractor AL P*� Date DESCRIPTION OF WORK Ct
NEW $
/ ADD
❑ I am exempt under Sec. ALTER FINAL l_S 99809, 1 A
i. ❑
B.BP.C. for this reason - t EPAIR DATE
Date: USE OF DEMOL ❑ FINAL - # •,• • • 2 1
EXISTING BLDG. BY C ,
Signature - - APPILIC NQeLNC N . - 2�• • 1 9,32
OWNER-BUILDER DECLARATION - j ,�
I hereby affirm that I am exempt from the Contractor's License AD ESY G� � ��•?i� '-'�f7 D _ e Vaa 1 q•3 2 czi
Law for the following reason (Section 7031.5,Business and av J <.1
Professions Code): - _ PRE - ���" �/
❑ I, as Owner of the'proper or m employees with BUILDING I ? 6
p p y, yADDRESS
wages as their sole compensation,will do the work and - LOCALITY
the structure is not intended-or offered for sale(Section. - '
7044, Business and Professions Code). MOVING TEL z8 O 9.2 A
El 1, as owner of the property, am.exclusively contracting CONTRACTOR NO. '
with licensed contractors to construct the project (Sec- ADDRESS
}� a •�e e.• 1
tion 7044, Business and Professions Code).
REQUIREDTOTAL SETBACK FROM EXIST. F
CONSTRUCTION LENDING AGENCY SET BACK YARD' HWY PROP. LINE WIDTH - 4300..
4,3 0 O csi
hereby affirm that there is a construction lending agency.for FRONT " • •
the performance of the work foi which this permit.is issued P.I.
jSec 3097, civ. C.), _ SIDE P.L. 12 0'6—8 2
Lender's Name
$ Lender's Address P.C. Fee$ .I Permit Fee
I cerflfy 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
G 'and herebyauthorize representatives of this County to enter
upon the above-menti n property for inspection urposes. - - - -
g �t^7r SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re pp¢ant or Agent / DoT> - ®s