HomeMy Public PortalAbout9662 GARIBALDI AVE_Building__ APPLOC AT*N FOR BUILDING PERMIT �
COUNTY OF LOS ANGELES . BUILDING AND SAFETY
WORKER'S COMPENSATION DECLARATION '*FOR APPLICANT TO FlLL IN
I hereby affirm that I have a cerdfcate ofconeerrt ro se#f hiaure, auNG ILDADDRESS
or a oertf Icate of lhbrkm' Compensation Insurance,or a oertffied E I
copy thereof(Sec.3800, Lab.C.) '
PdLy No. 1�14614n ,y ST&U FUND crrTEMPLE v P
CITY 91780 LOGwTY
SIZE OF LOT NO.OF BLDGB.NOW ON LOT
❑ CertHied Copy fa hereby fumlahed. NEAREST GROSS
M:CertHted oopy Is filed with the county bullding Inapectton TRACT BLOCK LOT N0'
t USE IDNE IMP NO.
para 11-1-93 „�,t RANDOL ROOFING ASSESSOR MAP BOOK FM3E PARCEL
SPecuL CONIxfle a
CERTIFICATE OF EXEMPTION FROM WORKERS' OW ER TEL No.
40
COMPENSATION INSURANCE SCI-OXYES?VATrN 1WO FT.OF SCI-O ? vt s
'M-k seatbn reed not be corvVated ff the permit fa for one hundred ADDRESS
I D�9Twcr GaouP coN9T. ZONE Paoct=ssEo BY
doklwB ($100) or leas) 96Q
certffy that In the performance of the work for Which tie permit 91780 �I1/
is Issued, I aha rpt empty any person In any manner ao as to ARCHf-ECT OR ENGNkER TEL Na
beoorne subject to the Workers'Compensation Lawn. STATISTICAL CLl:3Jj�1CATION APT CONDO
Date Ap leant ADDRESS CLASS NO. / DWELL U
MOTUE.TO AWLKANT ff, after making thla Certfflcate of REQUIRED TOIL SETBACK FROM E>39T
Exemption, you should become suboct to tf)e Wbrkers' CONTRACTOR TEL NO, SET BAG( YARD I WY PRP LTE WDTH
Compensation provlslorm of the Labor Code, you must iorthwtI:h 288-4040 FRONT
conVy with such provfabrm or this permft shell be deemed revoked. ADDRESS LIC.40. PL
51937 SrDE
LICENSED CONTRACTORS DECLARATION PL
hereby afflrrrr that I arrr Rearmed rxiderprwfajone of Ghap6ar.8 SAN GABRIll, CA =MAP
(commerdng wfth Section 7000)of Dfvlelon 3 of the Bush am end S0.FT.SIZE 110.OF STORIES 1 40.OF FAMLES
Profeeslons Code In full force and
f ff NEW E] aK PG ® d
License bar LIC.CDE9aRPT10N OF ADD ❑ WLUAQION O
con — 0 WITH 25—YEAR ALAR El $ 2 000.00 U
[I
I am exempt under Sec. CLASS A FIBERGLAS SHINGLES. REPAIR.
B.BP.C. for thle reason REROOF OVER EXISTING ROOF. DEMOL '❑ t LDW P/C+ LU
Datil USE OF EX19TM BLDG - URM Q - 1 .. 0-
AN
Signature APPUGANT(PFNVT) TEL N0. LDPenn r 1 Z
❑ 1, as owner of the property, or my errpkoyeee wfth wages ee EANDOL ROOFING 288-4040 - J- - - d- :�T.Lr
their axle oompensaticr, will do the work'and the stricture fa ADDRESS rE 3303
not Intended or offered for sale (Sectbn 7-044, Budrxm and Q ITEM
1
L 0 1 L
Profess101e Code.) wa.L THE APPL.IGNT oR FUTURE�D!!0 oc�PANT HANDLE A r�z�orie ori -
❑ I, as owner of the property, em exclrn�hety contracting with era A wrn�e ca INNING A HAZ.AFDOJaµwww EQUAL TO OR GFEArEi THA-THe
IlcerrSed contractota to oxetruct the project (Seadon 7044, YES El a e'No 0 ON THE rw�oc�eµArwALe r�oRµQgN« _ - FiNAL BY - TOTAL 102 . 30
YES❑ No❑
Business and Profeaaiorma Code.) WILL TUE rrrEroaD use of T1-e suDI-M BY THE APPUGxU OR ami£ BULDW � C+E, 14?.311
OCCUFM+T REQUVE A PERMIT FOR CONSTRUCT DN OR MODrrXION!FRD,r TUE SOUTH
CONSTRUCTION LENDING AGENCY corer AR ouwrry 6W"GI AENT DMTRICT W.ACAot ag PEFDAFlTrG a-easter wR �S ( .L30
I hereby affirm that there Is a cormtroatfon lendlrng agency for Ym❑ No❑ V —
w the performance of the work for which th}s permft Is issued( 11
3097, Civ.C.) '�aa�IST. UNoa� s�o►��Ina lriaE e�fa coAD urt 00DO 'J/ � �ti,
ITrLE 2 cHAPTEai 22o sEcraNe� Od rFROx3H 220.140 coNcEaa+G HAZARDOUS �+�'�' �^- 1 f 1 1•_
Lan6WIa Name uArwArS REPORTM A,�FGR A PS:MU FF"A T-E� _ ____._ 0736 1 AM 9:31.
Lender's Address
0 a1R6i W .. _.
I owttfy that I have read this application and state Under penalty P.C.FEE PE�111T Fly
of perjury that the above Inforrafion Is correct.I agree b 76.65
w wfth all county and State leve to
a my IsstuWE FEE
to for I 25.65
FNESTIGATION F E TOTAL FEE 102.30
Az
8EE REVERSE FOR EXPLANATORY LANGUAGE