HomeMy Public PortalAbout8756 GARIBALDI AVE_Building__ W6BKERS'CpMPENSATION DECLARATION
�;e Icrertlflate of Workers' Comcertificate
peof consent to nsatlonn Insures e, APPLICATION FOR BUILDING .PE IT
or a certlfled copy thereof (Sec. 3800, Lab. C.)
�J ,S1��Q7N/ArS 1 COUNTY OF LOS ANGELES � BUILDING AND SAFETY
Poll Nb. ��[Company Ar�kNu BUILDING
ICertlfled copy Is hereby furnished. FOR APPLICANT-TO FILL IN ADDRESS
❑ Certified copy Is filed with the county building Insp•c- BUILDING TS-6 QI S-71
tion department. ADDRESS
Date Applicant CITY ZIP LOCALrTY U
I ICATE OF EXEMPTION FROM WORKERS �20CK
INO. C1F BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NCrN OlJ L t ST.
(This section need not be completed If the permit Is for one - ASSESSOR
hundred dollars (=100)or less.) T'� � LOT NO. MAp BOCK PAGE PARCEL
I certify that In the performance of the work for which this NO' USE CXJE tlO•
permit WIssued, I shall not employ any person In any manner - / CLAL
CONNf75 -
so os to become subject tolKe Workers'Compensation Laws_ IQ
CITY ZJPDate
C�
NOTICE TO APPLICANT: If AppII icantafter making this Certificate of 's' NRCH ITECT OR NOO• )145 DISTRICT LFP TYPE HIRE BY
Exemption, you should bocome subject to the Workers' CONST• lott
Compensation provisions of the Labor Code; you must forth- ADp 23 1
with comply with such provisions or. this.permlt shall be 0'
doomed revoked. CONTIL4CTOR v No.
CONTRACT STATIST1G11 CLASSIF T10N APT. N
'/ Z
LICENSED CONTRACTORS DECLARATION L� . CLASS NO.=DWELL-LIN
I hereby affirm that I am Ilcerued under provision of Chapter 9 ADDRESS NO. 2
(commencing with Section 7000)of Dlvlslon 3 of the Business and ur- SEWER MAP �R
Professions Code, and my license is In full forand effect. CITY �-' CLASS BK. PG. VA&PA A
SQ FT. NO.01 NO.Cl: C hT_CK o • o • 3
Llcohse NUmbbr f(J rf_l Llc.CI S� STORES FAMILIES Otl& '1
C.ontractar Date DESCRIPnoN-OF WORK taw AM ; ,`�6- Q u • 23 7.8.0 .
�.I am exempt under Sec 9 ALT 237. 806
ALTER 1. Q 9 y 8 7
B.BP.C_ for this reason NGLoS /1T REPAIR _
USE
Date: EYJSTING BLDG.
SIgrwture APPLICANT / TEL ,xiC SAL..
OWNER-BUILDER DECLARATIOPL PRINT liC� NO. DA
I hereby afflrm that I am exempt from the Contractor's License A r+ J U lea G
Law for the following reason (Section 7031.3, Business and J
MtAVI
Professions Code):
BUILDING8 7 a 6
I, as owner of the property, or my employees with ADDRESS f 0 0 0
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Sedloo LOCALITY' 49rr eA 1 - 29G2 5-
7041, Buslness and Professlons Coded' MOVING TEL '
I, as owner of the property, am exclusively conirocting OR NO. 2 9,Q 2 5� '
with licensed contractors to construct the project (Sec- ASS 1. 1 51-8 8
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY TOTAL SETBACK FROM
SET BACK YARD FM1HI PROP. UNE WIDTH _
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit Is Issued, P
(Sec. 3097, Clv. C.). SIDE
P.
Lenders Name LD"Ref. #
$ [Inv—v�wigafl
CfPermtt Fee r7 V7Lender'sss Addrej c.rrlfy that I have read this appllcatlon and state that the Issu —F« P/C i
above Infomtlwon Is carred. I ague to comply w11fi all County on N
ordinances and Slate laws relating to building corntruction, ToraI Fee LDMA Perm.
and hereby authorize representatives of,this County to enter
upo. tpe ve-nentioned perty for Inspection purposes.
o L� kite� MtZi1/QSZ AOR DQLAl1ATORY LA7i01JA01
rwt.of ApplLcont or Agent