HomeMy Public PortalAbout9227 GARIBALDI AVE_Building__ WORKERS'COMPENSATION DECLARATION /
hereby affirm that I have a certificate
of consent to self A P P L I CATION FOR BUILDING PERMIT Il
Insure, or a certlflte of Workers'Compepenstlon Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
PollEyQo.20 412 3&kW Argonaut
Certified copy Is hereby furnished. BU I FOR APPLICANT TO FILL IN D4N ,7
Certified copy Is filed with the county building InsP�- BUILDING
;U( RESS
tion department. ADDRESS 9227 Garibal Hi LOCALITYNEAREST -7
/ G
Date • 1 1 —1 —83 AppllcantHQ'9hMr(i L: RandolCo z1P91780 GROW F. '
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BUGS. ASSESSOR
COMPENSATION INSURANCE Sia of LOT NOW ON LOT MAP BOOK PAGE PARC$
(This section need not be completed if the permit Is for one IkSE ZONE MAP
hundred dollars (;100)or less.) TRACE �� LOT NO.
/f SPEClA1
IL
Z285-56,75 CONDrri)NS O
I certify that In ihe,perionmarice of the work for which this DISTRICT GROU TYPE FIRE Y U
permit Is Issued, I shall not employ any person In any manner ,/
so as to become subject to thq Workers'Compensatlon Laws. ADDRESS �� CONST. ZONE O
Date 12-28-19$,�llu�oward L. Randol Co cmr
ZIP �7 G
STATTSf1CA1 CIASSIF}CAT10N CONDO.
NOTICE TO APPLICANT: If, after making this Certificate of ARCHTECT, TEL W ,
Exemption, you should become subject to the Workers' ENGIt�R NO. CLASS NO. DWELL- UNITS tL
Compensation provisions of the Labor Code, you must forth- N
with comply with such provisions or this permit shall be ADDRESS �R,�� Z
deemed revoked. ` CONTRACT L R o ;t.288-4040 B+c ��, n7 VAUDATION
LICENSED CONTRACTORS DECLARATION LtC
I hereby affirm that I am Ilcensed unclef provisions of Chapter 9 - - ADDRESS NO. VALUATION
(commencing with Section 7000)of DlvWon 3 of the Business and UC
Profoulons Code, and,my license Is In full force and effect. CITY CLASS- S 7 0 0, 0 0
SQ. FT. NO. NO. OF CHECK
License Number 3-86086 plc.Class- C-39 SJZE STORIES FAMILIES ONE
NEWS
ConiEOVar T,. Rand -
Randal Date12-28— 982 DESCR I PTION OF WORK ❑
I am exempt from the licensing requirements as I.am a ADD ❑
licensed architect or a registered professional engineer ALTER ❑ FINAL.
acting In fey profeulonal capacity (Sectlon 7051, REPAJR DATE �� d
Business and Professions Code). USE OF FINALEXISTING BLDG. DEAtiOI ❑ Is �X—`1
Llc.or Reg.No. Date APPLICANT TEL r �.._
OWNER-BUILDER DECLARATION PRINT _20.288-4040
I hereby affirm that I am exempt from the Contractor's License 2�,
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code):
BUILDING
I, as owner of the property, or my employees with ADDRESS
i wages as thelrsole compensation,will do the work and LOCALffY 8 8 b A
the structure Is not Intended or offered for sole (Section
704", Business and fsrofeulons Code). MOVING TEL
[,as owner of the property, am exclusively contracting ONTRA`CTOR NO. 0 0 o e o
with-licensed contractors to construct the project (Sec- ADDRESS 2 e e 2 a 0 0
tion 7044, Buslneu and Professlgns Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SFT BACK YARD FrWY PROP, LIE WIDTH at* 0 2 Fi O
I hereby affirm that there Is a construction lending agency foe FRONT
the performance of the work for which this permit Is Issued P.L 8 3
(Sec. 3097, Civ. C.). SIDE
P.L.
Lenders Name
Lenders P.C. Fee S Permit Fee
Addreu
I certify that I have read this application and state that the tssuanc•FM 8 . 50,
above Information Is correct. I agree to comply with all County Investlgatlon Few
Incas and State laws relating to building construction, - Total Fee
and hereby authorize repreaentotives of this County to enter
upo the aboye-mentioned operty for Inapectlon pu
l SEE REVERSE FOR"PLANATORY LANGUAGE
aSPUG _
^ Ignature of App IIcan n I D.16