HomeMy Public PortalAbout4949 FIESTA AVE_Building__ WORKERS' COMPENSATION DECLARATION 1 -
` iQsure,orairmPthat afcertificate of Workers' Compensat on Insurancef APPLICATION F.O k B U LLMN G PERMIT
or a certified..copy thereof (Sec. 3800, Lab.. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poli No. I o-5 company Sic. -e F�hGj
LYJ BUILDING
Certified copy is hereby furnished. . FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with th c nt buil 'ng inspec- BUILDING
tion department. ADDRESS
CITY' — ZIP 7 /d" " LOCALITY
Date Applicant NO. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT 2 NEAREST101
CROSS ST.
•`. COMPENSATION INSURANCE ASSESSOR' G/ �,�}
(This'section need not be completed if the permit is for one TRACT BLOCK LOT NO: MAP BOOK �7�, PAGE �// PARCEL GCS
hundred dollars ($100) or less.) TEL
OWNER KD�er -fINO.. f USE ZONE OP JL 617'T
1 certify that in the performance of the work for which'this �� i_ SPECIAL a
permit is issued, I shall not employ any person-in any manner ADDRESS CONDITIONS
so as to.becorre subject to the Workers' Compensation Laws. 0
CITY "ZIP
Date Applicant ARCHITE_ R TEL. rY
NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER w �$,tlSa� NO DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZONE 0
Exemption, you should become subject to the Workers' U
Compensation provisions of the Labor Code, you must forth- ADDRESS r� e�1� G• �� fld 3 Y '�G a
with comply with such provisions or this permit shall be 1 r°S Cohn NO. —0� STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR t Z
LICENSED CONTRACTORS DECLARATION j
LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS /YleYCQ NO. 616595-LIC. SEWER MAP ,
(commencing with Section 7000)of Division 3 of the Business � .•,.,-t.
and Professions Code,and m license is in full force and effect. CITY ( (�/ /� CLASS � tf BK `- PG " ='-VALIDATION
SQ. FT NO. OF NO. OF ` CHECK
r f� ,� r SIZE STORIES / FAMILIES C ONE
License N r `� `�' Lic. Class
G VALUATION
Contractor Date ��
DESCRIPTION OF WORK ( / �JdJ�< NEW � $ � ! L A, ���
❑ J �'�('/Cl hC fay w ADD J {r?"`h ► _ s�a: _ ;_`
I am exempt under Sec. � •_
. Q,. a ALTER ❑ � ;.5�..•::. ....., }_.
B.&P.C. for this reason //� ' REPAIR ❑ $
USE OF
Date:
EXISTING BLDG..1•/r. DEMOL ❑
APPLICANrT• � / TEL. 2Ocs`
tSi nature (PRINT) ✓L' NOFINAL
+ u t ly rOWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License ADDR¢$"S 7 �%- U1QLs�c SToL• FINAL-,
Law for the following reason (Section 7031.5, Business and �
Professions Code): PRESENT B
Y
❑ LDI NG
1, as owner of theproperty,.or m em to employees with ADDRESS
Y P Y ADDRESS •;:,;c-••-�:�- ,,•
wages as their sole compensation,wiI I do the work and , -;
the structure isnot intended or offered for sale(Section / ' LOCALITY
7044, Business and Professions Code.) MOVING TEL. _ _ w
CONTRACTOR NO. c ;: ;:••-
❑ 1, as owner of the property, am exclusively 66hfracting IHNIX a"t
with licensed contractors to construct the project (Sec- 7ADDRESS R
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 3 f w
I hereby affirm that there is a construction lending agency for FRONT
a
The performance of the work for which this permit is issued P:L. �r'_•; •,, i�� :; w,
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name. /
P.C. Fee$ (J � LDMA Ref. #
Permit Fee
Lender's Address q
o I certify that I have read this application and state that the Issuance Fee c2� • �c� LDMA P/C#
8 above information is correct. I agree to comply with alt County Investigation Fee v� '1
0 ordinances and State laws relating to building construction, Toral Fee O '] LDMA Perm. #
¢ d hereby auth ri a representatives of this County to enter
o the abpv�- a toned property for inspection purpo .
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent D to