HomeMy Public PortalAbout4941 DOREEN AVE_Building__ WORKERS' COMPENSATION DECLARATION 1�1�n ^ -
il hereby affirm that I have a•certificate of consent to self An IJI•yll IC /[1\TIOM FOR BUILDING,e� PERMIT
insure, or o certificate of Workers' Compensation Insurance, 4'1111 11 LS //11 0 II V
or a'certiffed copy thereof{Sec 3800; Lab.'C.) COUNTY OF LOS ANGELES -' _BUILDING AND SAFETY
Policy No d38yy Company E- KAI.&
❑� Certified copy is hereby furnished. ol-y FOR APPLICANT TO FILLrIN ADDRESS
JF+ Certified copy is filed with the county building inspec- BUILDING 5/I ,QEEA/ rI✓
tion department. ADDRESS CITY.,
�
.Date Applicant CITY ' iii CIr CR'zIP (7/76`e LOCAUTv
tJO. OF BLDGS. NEAREST
' CERTIFICATE OF.EXEMPTION FROM WORKERS' SIZE OF LOT - NOW ON LOT CROSS SL
's- COMPENSATION INSURANCE ASSESSOR SpS •d
(This section need not be completed if the permit is for one TRACT BLOCK Oi MAP BOOK GG PAGE PARCEL 404
OL
ht.m&ed dollars ($100) or less.) USE ZONE MAP
OWNE OM y G. TEL. ,c,,/��s J
NO.J NO. �'/ J 27
I.certify that in the performance,of the work for which this t C ' ,L n�1 L.r. ��� SPECIAL - - Y
44
permit is issued, 1 shall not employ any person in any manner ADDRESS IJ 4r • Z.4 Pole m -s . CONDITIONS a
so as to become subject to the Workers' Compensation Laws.
CITY f ec.9D/A C + zip 9/oo(p o
Date - Applicant M ARCHITECT O$. ``'_'-'' q TEL. LL// d'
NOTICE TO APPLICANT: If, ofter,making this Certificate of -1) ENGINEER �/ J.+W Ir/QE/� Tt� NO. 7S'y61 "DISTRICT - GROUP CONST. ZONE TYPE FIRE PROCESSED BY Q
Exemption,;you should become subject to the Workers' '1 '' ,^1 /� D ,/ tt 11
Compensation provisions of the Lobor Code, you must forth- . .v ADDRESS .3 a E. L4./'O/(TE. 8 o,a �� -3 4 �ZL a
with comply with such provisions or this permit shall be \E. /L�� /� TEL N
deemed revoked. V CONTRACTOR ipe QLS OA)1p v-7,3 STATISTICAL CLASSIFICATION APT. CONDO. Z
LICENSED CONTRACTORS DECLARATION -- LIC. CLASS NO. 5�2 DWELL UNITS
I herefiy affirm that I am licensed under provisions of Chapter 9 ADDRESS 1S E• Ali Nvq �y7�
(commencing with Section 7000)of Division 3 of theBusinessUO SEWER MAP
CITY eAD/A- ca 9/0oiP
and Professions C�o1de��,//a,ndl'my li//ce--nse is in full force and effect, y7l� p CLASS BK PG VALIDATION
License Num,ber,2 T;4 IIP Lic. Class .'� SIOZE2;V-L , 5TOR05 / NO. OF CHECK
FAMILIES ONE
•p w {'''� ,p( VALUATION
I]alJE, .QCS ON �NG Ea'���V DES -.'•..ION OF WORK 8(� 1 Ly x.9-1 Ak NEW fCSI .$/73,
7,
' Contract Dafe Y / ADD ❑ / •
$/N6tiE R ALTER ❑
❑I am exempt under Sea ��' � $/Nb CE Fq(w // •
8.8P.C. for this reason r•., �pQQ' V
�' DSE OF
'�F.•S/D&aC REPAIR ❑ $ 1' ,u1.•
Date:' EXISTING BLDG. DEMO •'/'•
Signature- �� APPLICANT TEL. FINAL
OWNR-BUILDER DECLARATION (PRINT) v/D K. Ot-saW NOS7 -73SY /
I hereby affirm that I am exempt from the Coniroctoi s License ' e n S7 ^�� DATE
Law for the following'reason (Section 7031.5, Business and ADDRESS IIS E• Vf ��7 ,4 FINAL
Professions Code): - PRESEBy
NT - 1 -
❑ BUILDING
I, as owner of the property, or my employees.with \p ADDRESS _µ s' f - ` \ ��n` i
wages as their sole compensation,will do the work and V 3'� ,' 'r ` T
the structure is not intended or offered for Sale(Section LOCALITY ' D /•s ' \ 71:7 -11 - n
MOVING - TEL. , I r �' `
❑ 7044, Business and Professions Code.)
CONTRACTOR NO.
I, as owner of the property, am exclusively contracting //
with licensed contractors to construct the project (Sec- - - Y s
tion 7044, Business and Professions Code.) ADDRESS � j`
- RETQ RED, TOTAL SETBACK FROM t EXIST. . •'
- CONSTRUCTION LENDING AGENCY ,SET BACK YARD. HWV PROP. LINE WIDTH/ t J , ti 1 L Y r.,Ts "4IE-I
I hereby affirm that there is a construction lending agency for FRONT - s +.m v s\, 1 J��,} 2°:,� \• �: lSr„.
the performance of the work for which this permit is issued P.I. \` - _. ALI
(Sec..3097, Civ. C.). SIDE,. r• J -j
'
Lenders Name \\
$ .. . . " •• LDMARef a �`{,tib . So4 Lt^•fl�ifhl—J'Jili
P.C. Fee$ 3• Permit Fee 7 '
Lender's Address - 14✓'
/ f
'I'<ertify that' have read this application arid state that the Issuance Fee a7 J LDMA P/C a D
Sabove information is correct. I agree to comply with all County Investigation Fee - - yJ L�
'ordinonces and State laws relating to building construction,. Total Fee t -1• / LDMA Perm. a
a and hereby authorize representatives of this County to enter _
upon the above-mentioned property for inspection purposes. - •' - -
a
n SEE REVERSE FOR EXPLANATORY LANGUAGE,
Signature of Applicant or Agent Date -