HomeMy Public PortalAbout10526 FREER ST_Building__ WORKERS' COMPENSATION DECLARATION . -
' , ,,! �ersu �iy caffirm" that have.a•certificate of consent' self -APPLICATION �F O R BUILDING. PERMIT
' insures or,a certificatee of Workers' Cofnpensahon Insurance,
br a certified copy thereof (Sec'3800, Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ , Cernf ed copy is hereby furnished', FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building ,nspec.'; BUILDING ti _
tion department ADDRESS
ET �� 2%�A /� �►C l�-�� ' �.J�
Date Applicant-• CITY Q0�►% LCj - v/jY ZIP �I l f�� LOCALITY qL, -
CERTIFICATE,OF EXEMPTION FROM WORKERS' NO OF BLDGS NEAREST
COMPENSATION'INSURANCE SIZE OF LOT 'lam lO D NOW ON LOT I CROSS ST
(This section need not be completed if the permit is,for'one _ ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO MAP BOOK, PAGE PARCEL
NO 7�TEL ILJ7 USE Z NE MAP,:_
I'certify that,in the performance•`'of the,work for which this OWNER 1. �V N QW NO' ��
permit is issued, I shall not employ any person,n any manner ( ' SPECIAL
• so as to become subject to the Wo r 'C ensat La ADDRESS GI t� . CONDITIONS "
Date Applicant ` CITY v. .'f � lA►C-IC_ ZIP 1�f' -23 ,
ARCHITECT OR TEL- DISTRICT GROUP TYPE, FIR OCESSED BY
NOTICE TO APPLI NT If, after making, this Cer ic-ate of ��` NO _7 r ° .
ENGINEER CONST'. ZONE
Exemption, you ould' become subject to the Workers' pp -,-. ;;+
Compensation prov,sions:of the Labor Code, you must forth- ADDRESS
J Jul �+IAct�rtll3tir Fo�3►�da�✓j '�� "" �"�O " �° t`'
with comply'with such provisions or this permrt'shall 'be Q� TEL : STATISTICAL CLASSIF ATION„•' APT. - NDO._
deemed revoked. ; CONTRACTOR - 1L1J1 NO /}
LICENSED CONTRACTORS DECLARATION
LIC CLASS NO: DWELL. UNITS vr
s"
I hereby affirm that 1 am licerised under provisions of'Chapter 9 ADDRESS NO `I __
SEWER MAP
(commenting with Section 7000)of Division 3 of the Busihess and EIC 3307 944°.25
Professions Code, and,my!license is in full force and effect - CITY CLASS n V LI
BK• �{ PG.Ohl`.,
SQ FT NO OF NO OF CHECK
License,Number Lic Class SIZE 2 ( STORIES FAMILIES ONE t:
VALUATION . TOTAL 10?4:•
Contractor• Date. - ' DESCRIPTION OF WORK, 1J-e W 1511 d� NEW 'CHECK 1024 o5�
i n ADD ;❑ 4fft1� 4yiv iVL
I am exempt under Sec. 1l+? l"r� VJ L LLI
ALTER ❑ ''" , CHANGE � '��
B&P_C. for this reason USE OF? � ' v REPAIR' ,❑ s/; fJ ,' _
Date: l DEMO. P O
EXISTING BLDG ��.GA+.►"C . P %J ;i ❑ OOOO-DOQ1 t,I ,SIv ,
Signature APPLICANT TEL FINAL c7 °°.
OWNER-BUILDER DECLARATION PRINT). 'NO DATE ' 4u�7 �' W'I11 b
I hereby offrrm that I am exempt from'the Contractor's License nn
Law for the'following reason.(Section.7031 5, Business and ADDRESS T J R FINAL
Professions Code),. PRE ENT BY
—.teaBUILDING
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 ti
7044, Business and Professions Cbde) MOVING TEL
,�(
17�I I, as owner.of the property, am•"exclusively contracting ' rDE
TOR NO -
�-�C with licensed contractors to construct the project (Sec- -%
tion 7044, Business and Professions Code).
D TOTAL SETBACK F
CONSTRUCTION LENDING AGENCY K YARD HWY PROP LINE' WIDTH.
M X I
J,hereby affirm that there,is a construction,lending agency for r '
the performance of'the'work for which this permit is issued ?� 2.� tit. •,- y'•'
(Sec. 3097, Civ- C:) `01
Lender's Name -('}�l1 LDMA Ref q t i 4 e', r^. 1?;,t I V i_ Permit Fee .. ;Lender's Address 4 g I certify that I have read this applicotion'and•state that.thepp ssuance Fee.D � J LDMA•P/C"lt0 obove'information is correct.'I agree to comply with all County' on e
6 ordinances and State laws relating to building construction, n 7�, Total Fee / '/ D , .DMA Perm S
o ° and hereby authorize representatives of this County to;enter
up 'tlQe abov Antionedperty•for inspection purposes.,iiip
`o
A "Signoture
�r SEE REVERSE FOR EXPLANATORY LANGUAGE f Ap ant or Agent Date --0• r`V •:�! t`F,t `•1