HomeMy Public PortalAbout9826 DAINES DR_Building__ J
n •� r' WORKERS'COMPENSATION DECLARATION - -
+'hereby affirm that I certificate of consent Self A P P L I CAT ®N F d R BUILDING PERMIT
hnsure, or'a certificate off Workers'Compenstion Insurance,
e, or _
a certified copy thereof (Sec 3800, Lab C ) ' COUNTY OF LOS ANGELES BUILDING AND SAFET
Policy No Company 1
F Cerlified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING o2 e17 �- -
ADDRESS
Certified.copy is filed with the county building inspec- BUILDING qq
tion department ADDRESS O4.t0 D A )itie S LOCALITY
r NEAREST
�/
Date Applicant CITY � �/`� /i egg/�//4/ ZIP CROSS ST
o CERTIFICATE OF EXEMPTION FROM,WORKERS', J�qr�O OF S ASSESSOR
SIZE OF LOT
'COMPENSATION INSURANCE NOW ON LOTMAP BOOK \ PAGE PARCEL
USE ZONE MAP `
(This section need not be completed if the permit is for one TRACT FV-6 BLGCK LOT NO NO
hundred dollars ($100)or•less )
�y e TEL / SPECIAL d
I certify that to the performance.of the work for which this. OWNER �/r�J q Ir 1 �p�/Vt �i NO��n� CONDITIONS \ Q
permit is,issued, I shall not employ any person in any mannerJ9�J DIS ICT GROUP TYPE \ FIRE PROC SED BY V
ADDRESS Js�s{t OC/ i CONST ZONE
sops to become subject to the Workers'Compensation Laws O
Date�l�i '.�� �Nio �-� I�D�wI aTY �►1a�f [►'/ /�-' ZIP_
Applicant STATISTICAL CLASSIFICATION APT, CONDO V
NO_fICE TO APPLICANT If, _bfier making this Certificate of ARCHITECT OR TEL
CLASS NO DWELL UNITS
Exemption, you'should become subject To the Workers' ENGINEER NO N
Compensation provisions of the Labor Code,-you must forth- ADDRESS SEWER MAP �
with comply,with such provisions or this-permit shall be TEL
deemed revoked CONTRALTO ,✓T?/1/ � fl G NO,i r.e6�+3 ,BK PG,' VALIDATION
s LICENSED CONTRACTORS DECLARATIONLIC
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �V4V� 4� ►,� 6��NO � I VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC' y I $
Professions Code, and my license is in full force and effect CITY 5� � CLASS' 1
+�,�I SQ FT �r NO OF, NO .OF CHECK
License N6mberJ3 d 44 6c Class 181 SIZE 8't` STORIES FAMILIES t ONE
�//7�J1'/��� /
Con6actafT�rr� u7 1�el'12- te' ! DESCRIPTION OF WORK ���//�'� NEW
O I am exempt from the licensing requirements as I am a ' 75,
�(/s1%)/e� ADD
licensed architect or a registered professional engineer j ALTER' FINAL
acting to my professional, capacity (Section 7051, REPAIR DATE
Business"'and Professioris Cade) USE OF �` R�/r� ! DEMOL FINAL �L
EXISTING BLDG, . S1�dr / dGr F yy W By
Lic or Reg No Date APPLICANTPR N ) Q✓�.^� �� �7'e4j NO ;L 6A
OWNER-BUILDER DECLARATION o � �`� / / �+�
I hereby affirm that I am exempt from the Contractor's License ADDRESS /7�} l Y/.: ie.r�1, / p/'r
Law for the following.reason (Section 7031 5, Business and
Professions Code) PRESENT
BUILDING
1, as owner of the property, or my employees with ADDRESS '
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
1, as owner of the property, am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code) 1 9 0 A
CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBACK FROM "EXIST
SET BACK, YARD HWY PROP LINE WIDTH
I hereby affirm that there is a construction lending agency for- FRONT ' # 0'0 0 0 0 1
the performance of the work-for which this permit is issued P L'
(Sec 3097;Civ C ) SIDE 2'- 1 4 2 0'0-
P L
Lenders Name o e 1 4200'
P C fee$ Permit Fee O 2 8,_8 O
Lender's Address
w '-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
ordinances and State'lows relating to building construction,.
Total Fee -
and hereby out representatives of this County to enter
cu n the above-mentioned property for inspection purposes
a ®~�.� ( '�a SEE REVERSE FOR EXPLANATORY LANGUAGE
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®S
,Signature of Applicant or Agent Date