HomeMy Public PortalAbout9237 FLAHERTY ST_Building__ 1 I`
I WORKERS' COMPENSATION DECLARATION
insure, or afcertif caafirm ne of Workers' ComipensaT on Insurancent to e, APPLICATION F OR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. BUILDING
.FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING ti _C� >�� . T
tion department. ADDRESS 9'!
Date Applicant' CITY 70;n ZIP LOCALITY
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 LOT NO. MAP BOOK PAGE PARCEL
hundred dollars($100) or less.) c-- TEL. USE ZONE MAP
OWNER 4�. 4 X.� . Al: e..1 NO. NO.
I certify that in the performance of the work'for which this
permit is issued, I shall not employ any person in any manner ADDRESS �.r �� � SPECIAL >_
�T CONDITIONS
so as to become subject to the Workers' Compensation Laws. O
�t�1 a a CITY' sr r ee C.l ZIP U
Date Applicant tl� T1T�� ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE R ESSED BY
NOTICE TO APPLICANT: If, after making this Certificate. of ENGINEER NO. CON57. Z E 0
Exemption, you .should become •subject to The Workers' j® 3 _ W
Compensation provisions of the Labor Code, you must forth- ADDRESS C1 p
with comply with such provisions.or this permit shall beTEL. / STATISTICAL CLASSIFICATION APT, CONDO. N
deemed revoked. CONTRACTOR 19,, NO. Z
LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed 'under provisions of Chapter 9 ADDRESS 1 tO 4AeC, NO. ;/j 617"?
(commencing-with Section 7000)of-Division 3 of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force-and effect. CITY +;f�JQ �f s7 CLASS �` BK PG. VALIDATION
/2' SQ. FT.,/,f NO. OF NO. OF CHECK
License Number 46 �ny O f� Lic. Class 's /$ SIZE ,/ / STORIES FAMILIES ONE VALUATION
Contractor �' C' v/ ' ��" Date s r DESCRIPTION OF WORK j� j "` 1�1�� �L NEW ❑ $ f s-Z p ��
❑I am exempt under Sec. �' "1114 irPry E>)"4' Q� ADD ❑ ,
ALTER ❑
B.BP.C. for this reason $
—�— �( USE-OF REPAIR ❑
Date: EXISTING BLDG. DEMOL ❑
ur L/ APPLICANT TEL.
SignatFINAL
OWNER-BUILDER DECLARATION (PRINT). NO. DATE •.1, W
I hereby affirm that I am exempt from the Contractor's License
_
Law for The following reason (Section 7031.5, Business and ADDRESS FINAI '`� "
Professions Code): .PRESENT By
,t ❑ I, as*owner of'the property, or my employees with BUILDING
ADDRESS
G"
wages as their sole compensation,will do the.work and �l
( LOCALITY , � L //�/
the structure is not intended or offered for-sale Section _ __
7044, Business and Professions Code:) MOVING TEL. U 1 !\I `�
I, as owner of the property, am exclusively,contracting
CONTRACTOR NO. L 1
with licensed contractors to construct the project (Sec- , r= —F
ADDRESS l-? � �' S
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIITTH
'
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WID $•' �' E' _--
I hereby affirm that there is a construction lending agency for FRONT :•s;"T
the performance of the work for which this permit is issued P.L.
`5
(Sec. 3097, Civ. C.). SIDE
P.L..
Lender's Name. LDMA Ref.P.C. Fee$ Permit Fee b�,Lender's Address _•„ _ _ H ; _
oI certify that I have read this application and state that the Issuance Fee LDMA P/C#
above information is correct. I agree to comply with all County Investigation Feeordinances and State'laws relating to building construction, Total Fee e. OLDMA Perm. #
a and hereby.authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date