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Home My Public Portal About9036 ELM AVE_Building__ WORKERS' COMPENSATION DECLARATION / , G 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 cppy thereof (Sec. 3800, Lab. C ) �- COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. 7-5VCompony f4& �� 7 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADR SS Ca' Z' Certified copy is filed with the unty building inspec- BUILDING / tion department. ADDRESS �� LOCALITY ✓� / i� NEAREST Date"'�/` Applicant !"" CIT ZIP CROSS ST. CERTIFICATE OF EXEMP ON 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 one USE ZONE MAP G/ hundred dollars ($100)or less.) TRACT BK LOT NO. NO. TEL �h '1 &nom j^(/ SPECIAL I.certify that in the performance of the work for which this OWNER NO I CONDITIONS permit is issued, I shall not employ any person in any manner77Y DISTRICT GROUP TYPE FIRE PR SSED BY V . so as to become subject to the Workers'Compensation Laws. ADDRESS S elf �/1 CONSTZONE f/ a /� Date Applicant CITY ZIP TEL. STATISTICAL CLASSIFICATION APT. CONDO. _ NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR ENGINEER NO. CLASS NO. ' "� DWELL. UNITS Exemption, you should become subject to the Workers !9i Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be /� deemed revoked. No7 S7?�re BK. k PG, � VALIDATION CONTRACTOR NO 71�"' LICENSED CONTRACTORS DECLARATIONLIC, I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS le- N 5��, VALUATION (commencing with Section 7000)of Division 3 of the Business and - LIC. e_ Professions Code, and my license is in full force and effect. CITY _ CLASS `7' $ SQ. FT. NO. OF NO. OF CHECK License Num Lic.Class y� SIZE STORIES FAMILIES ONE �� $ Contract Date DESCRIP N OF WORK NEW ElADD I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer ALTER FINAL acting in my profbssional capacity (Section 7051, REPAIR DATE Business and Professions Code). USE OF DEMOL FINAL EXISTING BLDG. By Lic.or Reg. No. _Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business,ond ADDRESS Professions Code): PRESENT El 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 sole(Section LOCALITY ;2 41 7,4 A 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. # 0 0 0 0 0 1 with licensed contractors to construct the project (Sec- ADDRESS 2 ° - 38.50 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH .o 0 0 385005 I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. ��6. 0 1 —82 (Sec. 3097, Civ. C.). SIDE- P.L. Lender's Name � Lender's Address P.C. Fee$ Permit Fee .• w 1 certify that I have read this application and state that the Issuance Fee '10 above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee reby authorize representatives of this County to enter < upon t e above-menti roperty for inspection purposes. v a � SEE REVERSE FOR EXPLANATORY LANGUAGE ^ Signature of Applicant or Agent Dote ©s