HomeMy Public PortalAbout9842 FLAHERTY ST_Building__ B� sk
" wERS' COMPENFSATION DECLARATION
'htreby affirm thCt I have a certificate of consent to self A P P L I CAT I O -F- 0 R n, "I L D N IG ' PERMIT Y
insure, or a certificate of Workers' Compensation Insurance,
orw qeitified copy thereof (Sec. 3800, Lab. C.) a10 ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
?�j/39Company ���3 �!/NQ
Policy Novi ,
ElCertifiedcopy is hereby furnished. UILDI NG FOR BUILDIN
R APPLICANT TO FILL IN ADDRESS ��v� -
❑ .Certified copy is filed with the county building inspec- ADDRESS q842- FLT MTy
// tion department.
V Date ~�^( Applica v CITY` Cj ZIP LOCALITY
CERTIFICATE OF EXEMPT OfN FROM WORKERS' SIZE OF LOT 0.0 X LOT CROSS ST. U Gl
13Js NOW ON NO OF BLDGS.
NEAREST
G
COMPENSATION INSURANCE v j �,� ASSESSOR p
(This section need not be completed if the permit is for one \ TRACT )4'0 BLOCK LOT NO. MAP BOOK 3D a� PAGE G� PARCEL
hundred dollars ($100) or less.) `- TEL.
OWNER Iv�F'.ryYS.�}�t»tGS �Cir� NO. -QQ '�. USE ZONE MAP
NO.
I certify that in The performance of the work for which this \ _ SPECIAL
permit is issued, I shall not employ any person in any manne ADDRESS 5005 � c1 B ff / CONDITIONS a
so as to become subject to the Workers'Compensation Laws. - I O
y\� CITY ZIP U
Date Applicant 1 ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER 0.L1Ti '�^ ,-Z- DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZONE O
Exemption, you should become subject .to the Workers' /�/� c U
Compensation provisions of the Labor Code, you must forth- ADDRESS 2,490-7 Lmq•. S. EJ MO�CA ,Q1 -2a �-� ��f���� a
with comply with such provisions or this permit shall be - TEL.&!r STATISTICAL CLASSIFICATION APT. CONDO. V)
deemed revoked. CONTRACTOR :`: NO. VY3 DWELL. UNITS Z
LICENSED CONTRACTORS DECLARATION /� p LIC. CLASS NO.-451 2-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS�7�D S-1�. L.$OK NO.✓�z�?
(commencingwith Section 7000)of Division 3 of the Business <+� VIGCt 141. LIC. SEWER MAP
�JZ 3 2 CLASS � F
and Professions Code,and my license is in full force and effect. CIN BK PG '�"VA[IUATION
�j SQ. F OF NO. OF CHECK -"
License Number SZo5Y0 Lic. Class /_ -1 SIZE STORIES 2 FAMILIES ONE
VALUATION
C? G-�-Q3 �, DESCRIPTION OF WORK '; G- NEW
Contractor Date ADD ❑ SW�� I :+ :.ac;r i;
ElI am exempt under Sec. 't.x15 �F C:oY1S�i"ut�+0 �rlda
ALTER ❑ �// 0,
B.BP.C. for this reason 2-5 t;; ,�,(�� ❑ $ i _°� ? -
REPAIR =..:
USE OF
Date: EXISTING BLDG. a OOO. "Y�""'a#+.F+_
j DEMO' Elj_-
Si natur APPLICANT
OWNE -BUILDER DECLARATION (PRINT)f l0.cit:GO _ Zia FIy
I hereby affirm that I am exempt from the Contractor's License ` - y� 40n DATE -2— Y ;� ••.._s yr' {
Law for the following reason (Section 7031.5, Business and A DRESS Loma S:�� '='H FINAL %�f/jjJ
Professions Code):. PRESENT By ,��` ss
I, as owner of The ro eri or em to ees with BUILDING I+,it_,!_I FII t�: :^
P P Y m Y P Y N ADDRESS _
compensation;wages as Their sole will do the work and 0
j� f t i •cs'
9oi ylti L �ii{ltloi_=
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL yr
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors To construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) O ,!A
t REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. / �V r
CONSTRUCTION'LENDING AGENCY SET BACK PROP. LINE WIDTH �q,1`
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.
Lender's Name �Jq
S /7 / �} / LDMA Ref. #
Fee$ / o Permit Fee tY/�/• [J
P.C.
3 Lender's Address q C� //
P poll
0
I certify that I have read this application and state that the /' / Issuance Fee �(O� LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee sl
ordinances and Slate laws relating to building construction, Total Fee 1 LDMA Perm. #
a and hereby authorize representatives of this County to enter
au e above-m coned property for inspection purposes. i
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Applicant or Agent Date