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HomeMy Public PortalAbout9044 ELM AVE_Building__ WORKERS' COMPENSATION DECLARATION 7 �- hereby affirm that I have a certificate f consent to self APPLICATION FOR BUILDING PERMIT insure,or a certificate of Workers'Comp tion Insurance, or a certified copy thereo Sec. 3800, Lab COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N�_JCompon u BUILDING j Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 5 Certified copy is filed with the county building inspec- BUILDINGpp tion department. ADDRESS a �„ LOCALITY !� NEAREST Date D Applican C ZIP CROSS ST. CERTIFICATE OF EXEM ION 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 MAPS hundred dollars ($100)or less.) TRACT BDr BOCK LOT NO. / NO. 7 y TEL. / SPECIAL I certify that in the performance of the work for which this OWNER NO. OL CONDITIONS ji.:�� ` f O DISTRICT GROUP TYPE FIRE PRO ESSED BY lJ permit is issued, I shall not employ any person in any manner J / r so as to become subject to the Workers'Compensation Laws. ADDRESS �4 / 3 C� � CONST ZONE _ / 019 Date Applicant CITY ZIP / STATISTICAL CLASSIFICATION APT. CONDO. G NOTICE TO APPLICANT: If, after making this Certificate of ARCHITE TOR TEL. J191 Exemption, you should become subject to the Workers' ENGINEER NO. CLASS,NO. DWELL. UNITS s` N Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be / deemed revoked. CONTRACTOR TEL. �� BK A6 PC4 VALIDATION NO LICENSED CONTRACTORS DECLARATION �/� I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. L, �� Professions Code, and my license is in full force and effect. CITY . CLASS $ �p f ' SQ. OEFTI STOROF FNO ES AMILOIES CHECK License Numb �✓�S/ '� Lic.Class G—`--/��/— ❑ Contractor Date / L,— DESCRIPTIOF WORK NEW ❑ I 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 G Q REPAIR _ Business and Professions Code). USE OF DEMOL FINAL EXISTING BLDG. By �s Lic.or Reg. No. _Date APPLICANTTEL RIM OWNER-BUILDER DECLARATION (P �'L�� a„s IN �r� I hereby affirm that I am exempt from the Contractor's License //�� Q 4 Law for the following reason (Section 7031.5, Business and ADDRESS /L,lG� L—T'/4�E.f�/� Professions Code): PRESEN BUILDING El 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 z�4 1 �,5 r 7044, Business and Professions Code). MOVING TEL. I, as owner of thero ert am exclusive) contracting CONTRACTOR NO. P P Y, Y 9 # 000001 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). 2 0,0 38.50 CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. • SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT o a o 3 8,5 0 0 the performance of the work for which this permit is issued P L. (Sec. 3097, Civ. C.). SIDE 0'6 0 �1 -82 o P.L. Lender's Name m Lender's Address P.C. Fee$ Permit Fee J0 r wI certify that I have read this application and state that the Issuance Fee - Si J g above information is correct. I agree to comply with all County Investigation Fee d 0 ordinances and State laws relating to building construction, Total Fee l and hereby authorize representatives of this County to enter he above-menti d operty for inspection purposes. a r`^ L SEE REVERSE FOR EXPLANATORY LANGUAGE Air_ Signature of Applicant or Agent Date ©s