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Home My Public Portal About9032 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 certifi d copy thereof (Sec. 3800, Lab. C.') � �� c� CCOUNTY OF LOS ANGELES BUILDING AND SAFETY Policy (,`U 7.5r Company BUILDING , Certified copy is hereby.furnished. FOR APPLICANT TO FILL IN ADDRESS 76- Certified copy is filed with the county building inspec- BUILDING �4-_' / tion department. ADDRESS D�Y C+J�7�Y LOCALITY //.nn��j NEAREST Date Applicant /l� CI ZIP CROSS ST. �.��-�t� CERTIFICATE OF EXEMPT N FROM WORKERS' 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 oneTRACT USE ZONE MAP � Q hundred dollars ($100)or less.) BLKK LOT NO. NO. � TEL ��ry/� SPECIAL 7p� OWNER NO TJZ. CONDITIONS '7i!J /L' J '� I certify that in the performance of the work for which this �s DISTRICT GROUP TYPE FIRE RO SSED BY. V permit is issued, I shall not employ any person in any manner ADDRESS �a CONST. ZONE �e so as to become subject to the Workers'Compensation Laws. L Date Applicant CITY ZIP ��" STATISTICAL CLASSIFICATION APT. CONDO. V im NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR EL. ENGINEER NO. CLASS NO. DWELL. UNITS 0. Exemption, you should become subject to the Workers' tH Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be Z deemed revoked. CONTRACTOR. NOT — p BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ^/J VALUATION z� (commencing with Section 7000)of Division 3 of the Business andLIC. Professions Code,,and my license is in full force and effect. CITYArX:��e � CLASS 47� L $ C—,2-1 SQ. FT. INC. OF NO. OF CHECK License Numb ©�5�, ic.ClasSIZE STORIES FAMILIES ONE NEW � $ Contractor Date DESCRIPTIO OF WORK EJI am exempt from the licensing requirements as I am a ADD licensed architect or a registered professional engineer ALTER FINAL acting in my professional capacity (Section 7051, ❑ DATE REPAIR Business and Professions Code). USE OF DEMOL FINAL EXISTING BLDG, Y Lic.or Reg. No. _Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) G�� /P N07 ''ll-�I (,� I hereby affirm that I am exempt from the Contractor's License ADDRESS�O / 0 Law for the following reason (Section 7031.5, Business and Professions Code): PRESENT ❑ BUILDING 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). kADDR TEL. ❑ OR NO. 4 7,3 A I, as owner of the property, am exclusively contracting z with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). 0 0 0 0 0 1 TOTAL SETBACK FROM dT CONSTRUCTION LENDING AGENCY YARD HWY PROP. LINE 2 0'0 3 8 5 0 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097, Civ. C.). 0 0 0,3�j' 5 0.5 Lender's Name 0 6.0 1 -8 2 Lender's Address Permit Fee 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 laws relating to building construction, and Hereby authorize representatives of this County to enter Total Fee 2 y a U above-mentio operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE /e-Sri;-nature of Applicant or Agent Date ©s