HomeMy Public PortalAbout4823 FIESTA AVE_Building__ WORKERS' COMPENSATION DECLARATION
Z affirm that I have a certificate of consent t6 self
r a certificate of Workers' Compensation Insurance,
APPLICATION F O R BUILDING PERMIT
rtif,4 d copy thereof (Sec. 3800, Lab. C.)) COUNTY OF LOS ANGELES BUILDING AND SAFETY
„'81icy❑ No. /1_31_�,Un,34gr.Qpany !�' I�/tJL7
r BUILDING
Certified copy is hereby furnished.. . FOR APPLICANT TO FILL IN ADDRESS `Z 523 'l�ST
Certified copy is filed with the county building inspec- BUILDING Z �S7
tion department. > u 1 ADDRESS s�
p� ��un��e7'r���iug�� CITY- T ZIP '11790 LOCALITY n
Date 9-g �g Applicant -jA"MF.S A //r
NO. OF BLDGS.. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE'OF LOT NOW ON LOT / CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LO7 NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL' USE ZONE MAP )
OWNER C, -E/�LE NQ.Zg - �.S NO. O(
I certify that in the performance'of the work for which this
permit is issued, I shall not employ any person in'any manner ADDRESS 8 S SPECIAL
CONDITIONS O
so as to become subject to the Workers' Compensation Laws. U
CITY DLA e ZIP U
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE T FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONEU
Exemption, you should become subject to the Workers' j
Compensation provisions of the Labor Code, you must forth- ADDRESS t�� A` � �� a
with comply with such provisions or this permit shall be ,^ T al �/ STATISTICAL CLASSIFICATION APT. N
CONDO. Z
deemed revoked. CONTRACTOR �/ C7 —
LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. <2 UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS/_-3// L NO.0S
(commencing with Section 7000)of Division 3 of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITYS20 L_ CLASS BK L PG 1 VALIDATION
G J SQ. FT. NO. OF NO. OF CHECK
License Number 09(068 I Lic. Class ' / SIZE I STORIES FAMILIES ONE
/���� a L VALUATION
Contractor E�r�iYll�Pf/�U�/Il/)�D1�Date DESCRIPTION OF WORK NEW ❑ $ /90a
D0 ` 6
)0
E]I am exempt under Sec.
/ G S C_D/+L f��SI ADD ❑ ►
^7 LTJ
ALTER �,I
B.&P.C. for this reason /l0 REPAIR $
Date: USE OF
EXISTING BLDG. — DEMOL ❑
Signature /6�� Fq� I¢�p���� ,(J. APPLICANT TEL. G FINAL i
y O f rtip 11T -L PRINT) S G NO�a 7 ��
e ,tZN DATE' ,i
I hereby affirm tha a exe t rom e o r s tcert ��E� LQ �
Law for the following reason (Section 7031.5, Business an ADDRESS / !� FINAL >
Professions Code): PRESENT By lr, j A�•l•Tos
BUILDING
❑ I, as owner of the property; or my employees with ADDRESS `\% /Q��� ��(�1 3307-
wages as their sole compensation,will do the work and �. 1 ��E3
the structure is not intended or offered for sale(Section LOCALITY ' VV S
7044, Business and Professions Code.) MOVING TEL.
❑ I, as owner of the property, am exclusively.contracting CONTRACTOR NO. TOTAL ,f-9�8u
with licensed contractors to construct the project (Sec- ,G
tion 7044, Business and Professions Code.)
ADDRESS CHECK,
REQUIRED TOTAL SETBACK FROM EXIST. CHANGE
f
CONSTRUCTION LENDING•AGENCY SET BACK YARD HWY PROP. LINE WIDTH CHANGE .011
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.
(Sec. 3097, Civ. C.). SIDE
P.L. 0000-0001 9/ 8/89
Lender's Name. E
LDMA Ref. # �J90 1 Al�iltll
'
Lender's Address P.C. Fee$ Permit Fee
�
0 1 certify that I have read this application and state that the Issuance Feg .150 LDMA P/C# ,
above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction; Total Fe LDMA Perm. #
a and hereby authorize representatives of this County to enter
u the above-mentioned property for inspection purposes. /
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Applicant o Agent Date