HomeMy Public PortalAbout4939 DOREEN AVE_Building__ J `VORKERS' COMPENSATION DECLARATION II�� p//�� r,�p rr�r'"T /�
ipSure, o os certificate
that haver certificate C Compensation
tion Insurance,
self ,••q ��RD�IPaII(( w. Flyl_y1N T
�ipsure, orn certificate•of Workers' Compensation Insurance, .. /�-Q II Il L� R�16.tV Il ,B-V�dill _�Y"!'6 ,LTJ II V..�..3• / FERMT .
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or,a certified coy thereof(Sec. 3800 Lab C.) CdUNTY=OF LOS ANGELES• BUILDING'AND SAFETY_ u
•^Policy No.U�ompany C KAXb
� .� PIR PLICANTTO FILL IN BUILDING '"7� �1_e�rcr- Glr�l. •.
❑ Certified copy is hereby furnished.. - ADDRESS
Certified copy is filed with the county building inspec BUILDIN dQC�� - d ,� 7.
fi n department ADDRESS Il^ AIV o •.
Date _12/_ 1Ap icant - CJY- ^ L��.r. -� -A z,P-- ,1 Q O LOCALITv
NO. OF BLDGS. .` NFAREST.
CERTIFICATE OF-EXEMPTION FROM WORKERS' " SIZE O6 LOi ^" NOW ON TOT OA1� CROSS SL -
COMPENSATION INSURANCE ASSESSOR
' (This section need not be completed if the permit is for one TRACT BLOCK- LOT NO. MAP BOOK PAGE DI`s FARCEN
hundred dollars ($100) or less.) - • . A A We TEL z,(
• ,r• O E 5�7-7 USE ZONE MAP �-7:
,
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I certify that in the performonce.of the work for which this NO.
/9 _/- SPECIAL
permit is issued, I shall not employ any.person in any manner A DRESS ( OILSr./ /G CONDITIONS - d
so as to becomeisubjeat.to the Workers' Compensationdaws. , w O
'F, - . CITY OrA... C .ZIP rpo6- V
Date - Applicant ARCHITECT ,'L��' TEL. ��//�� ,DISTRICT GROUP TYPE FIRE PROCESSED By K
-,NOTICE TO,APPLICANT: If, after making this Certificate of ENGINEER V• poi �!F/f^� NO. S-TG( CONST. , ZONE �p
Exem tion, ou should become subject to the Workers' �• Q y'' A 99 / - V
Compensation.provisions'of the Labor Code, you must forth- ADORESSY 2 6 . th Pa •TC�iB IfrC[ 0//g- J�'nf �./ •3 G�1-L' a'
.with ,comply with such provisions or,this permit,shall be L .�p�y�
AC F/V a �.r - S74L T STATISTICAL CL4551FICATION APT. CONDO. Z
deemed revoked. - •- ` ^ CONTRACTOR YG N�•��+w .{- f
LICENSED CONTRACTORS DECLARATION 0 LIC q CLA55 NO. D`/ DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter `^2 ADDRESS S44C4+0
��t//�. ee /• 6 NO jql y7�
CITY C�lf'!rT `�- LIC. SEWER MAP
' '.(commencing with Section 7000)of Division 3 of the Business . G�,J CLASS -
and ProfessiansCode,and my license is in full force d effect. 77�(i _ BK. PG. VALIDATION
^ q SO. F / NO. OF NO. OF CHECK
Licenser-Numbers� 'Lic. Class �' SLZ 43 STORIES FAMILIES ONE
Contra206D T(KSOa _J /,t$�.6'- (_�/ DESCRIPTIONOF WORKN6W S/N6L.� ryEW VALVA/TyION - -
❑ am exempt under Sec. •w?'r' • —( I I - _ Sr N(a (,�`` �R/1(( ADD- ❑ S I��
GSIOtAI4 L ALTER ❑ D
B BP.C.-for this reason ,REPAIR ❑ $
Dater USE OF ._ _
EXISTING•BLDG. - /� (/ ^, U - DEMOL ❑ - GI
Signature. �� \ APPLICANT J/•%.D /�• 1�� NO.4-71111 FINAL - t
.O R-BUILDER DECLARATION • - (PRINT) Ay
IL
hereby affirm that I am exempt from the Contractor's License _ /I� LA Q ' A DATE -
Law for the following'reason'(Section 7031.5, Business and ADDRESS (J.. G% /aQ� - 'C�OrA° FINAL _
Professions Code) . PRESENT - -
- _ By
erof thePro property: or my employees with'E1 I, as ownBUILDING
wagesastheir:sole compensation,will dcuthe workand y, ADDRESS
t =
the structure Is not intended or offered for sale(Section LOCALITY Cf/.-f t L •-I.
- 7044; Business and Professions Code.) : MOVING • TEL. , D - _ \•
NO -
- CONTRACTOR . 7n t
❑' I, as owner of the property, am exclusively.contracting
With licensed contractors to construct the project(Sec-, - - / �`f.3•_ -.
ADDRESS
.tion 7044, Business.and Professions Code:) - �N
CONSTRUCTION LENDING AGENCY SETOBACKD YARD HWY TOTALPRSOP.ALINEFROM VJIDTM� \ ! `\-
I hereby affirm that there'is-a construction.lending agency for -FRONT -- X,t ) t `; �hti- r ?\ tltJlt E�,\�t, `. La ---•
the performance.af the.work.for which this permit is issued P.L. _-
(Sec. 3097, Civ. C.). SIDE' -
. P.C.- r P+ -
Lender's Name,
LDMA.Ref N t' . Tt t h - t l T-!
- .. P G Fee$
Lender's Address .J•� Perm iCFee• x L ,5\_\:� +` �'- I !- r- Ai",
a I certify that I haveread this application and state that the Issudrice fee LOMA P/C'R D —
8 above information is correct. I agree to comply with all County Investigation Fee'
ordinances and State Jaws relating to building construction, - Total Fee LOMA Perm. p
a and hereby authorize representatives of this Countyto enter
upon the above-mentioned property for inspection purposes.
' 1+ SEE_REVERSE FOR EXPLANATORY LANGUAGE _
Signature of Applicant or Agent Date -