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HomeMy Public PortalAbout9026 ELM AVE_Building__ WORKERS'COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers'Compenstion Insurance, or a certified cop thereof (Sec. 3800, Lab. ) J COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy S� Company . L!� 1-1 Certified"copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING tion/department. //�� ADDRESS �o e '�r -c�� LOCALITYNEARE G �'�! (� y A*3 �11 CIT ZIP CROSSS Date ST. Applica CERTIFICATE OF EXEMP ON FROM WORKERS'nt NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP _ hundred dollars ($100)or less.) TRACT BLK LOT NO. NO. a 7 >_ TEL /` h ,i SPECIAL f �� 0. I certify that in the performance of the work for which this OWNE __ NO (c�'tJ2 CONDITIONS `f3, CqeK permit is issued, I shall not employ any person in any manner DI TRICT GROUP TYPE FIRE PROCESSED Y 6J so as to become subject to the Workers'Compensation Laws. ADDRESS .2 S y r/ CONST. ZONE I p f o:� U d 3 Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO. 4a NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. ENGINEER NO. t CLASS NO. DWELL. UNITS Exemption, you should become subject to the Workers' N9 Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be deemed revoked._ TEL. �y BK PG K VALIDATION CONTRACTOR N 7 LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS � N d �lJ VALUATION 00 (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS C��— $ Y�� SQ. FT. NO.OSTO IE FA OF CH E License Num O Lic.Class —�,�/— SIZE STORIES FAMILIES ONE Coniracio Date DESCRIPTION OF WORK NEW $ ❑ ADD am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer ALTER FINAL �P � acting in my professional capacity (Section 7051, f 1�!/ DATE / REPAIR Business and Professions Code). USE OF DEMOL FINAL EXISTING BLDG. By Lic. or Reg. No. _Date APPLICANT TEL.. C OWNER-BUILDER DECLARATION (PRINT 'Fi TEL-7 �� ,�t'� I hereby affirm that I am exempt from the Contractor's License /,7� ,s No Law for the following reason (Section 7031.5, Business and ADDRESS 10 Professions Code): PRESENT El1, I, 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. I, as owner of the property, am exclusively contracting CONTRACTOR NO. z.4 1 7,2 A with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). { 0 0 0 0 0 1 REQUIRED TOTAL SETBACK FROM EXIST. ' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH � I hereby affirm that there is a construction lending agency for FRONT 2 °i° 3 R 5 0 the performance of the work for which this permit is issued P.I. (Sec. 3097, Civ. C.). SIDE ° ° ° 3 8 5 0 v P.I. Lender's Name 0'6 0 1 —8 2 Lender's Address P.C. Fee$ Permit FeedGI w 1 certify that I have read this application and state that the Issuance Fee O J above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee S11 aSdhneby authorize representatives of this County to enter au above-menti ed operty for insW,on purposes. �a< AV �v SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o A plica It 7Agent Date ©s