HomeMy Public PortalAbout4950 GLICKMAN AVE_Building__ W(''l •.-')MPENSATION DECLARATION '
insure,hereby
aa1 c,t : ,e of Workers' Compensation Insurance, AP P L I t .- . ION. FOR BUILDING PERM- ,
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy'No. 3Coimpany SY�Tr- T1ui.t
BUILDING -
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified co is filed with the countybuildingins ec- BUILDING S Ll�d M A
tion department. p ADDRESS Cj� GI,IG��✓v!!�N s L.
Date 3 �'�� Applicant CITY �( ZIP 9 LOCALITY _rC–M L—S CAz�
CERTIFICATE OF EXEMPTION FR WORKERS' SIZE'OF LOT tJ� NOW ON LOT NEAREST
'` CROSS ST. r-0 SA
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACTprp BLOCK LOT NO: MAP BOOK PAGED PARCEL
hundred dollars ($100) or less.) wrri TEL.
OWNER r7 /�rL y I r- v �'lJ, NO. USE ZONE MAP /(/�f 1`-�
I certify that in the performance of the work for which this II �J -f
NO. / !- / 7 !i�
SPECIAL >_
permit is issued, I shall not employ any person in any manner ADDRES 'WWF Q 4 CONDITIONS a-
so as to become subject to the Workers'Compensation Laws. O
CITY L-47 ZIP"p`0Q1 1 U
Date Applicant ARCHITECT OR TEL. Q
NOTICE TO APPLICANT: If, after making this Certificate of J� ENGINEER Gt kR, Np J DISTRICT GROUP TYPE FIRE PROCESSED BY O
CONST. ZONE,
Exemption, .you should become subject to the Workers' s ffJ� `/ U
Compensation provisions of the Labor Code, you must forth- ADDRESS �` E. /—�� V -r _ _ a
with comply with such provisions or-this permit shall be TEL. STATISTICAL CLASSIFICATION ' `- Z
AP7F CONDO.
deemed revoked.. \ CONTRACTOR Cv J,<—� NO.
LIC. h
�p CLASS NO. DWELL. UNITSLICENSED CONTRACTORS DECLARATION
I herebyaffirm that I am licensed under rovisions of Chapter 9 ADDRESS pNO.
SEWER MAP
(commencing with Section 7000)of Division 3 of the Business N, LIC.
S/
and Professions Code,and my license is in full force and effect. CITY G CLASS BK. L► PG.S Off,TO,44 LIDA
SQ. FT. NO. OF n NO. OF ( CHECK �' rye
License Number 510178 Lic. Class SIZE J STORIES IFAMILIES ONE --
VALUATION
Contractor i JDate 3 �TZ DESCRIPTION OF WORK fJ( I �1���.�� NEW S �� 0 0 t-.;,�,
w ► _t'1,%Cit ja
❑1 am exempt under Sec. 1� �'A.Gk� p �ON�[7 ADD ❑
ALTER ❑
B.&P.C. for this reason --
REPAIR ❑ $ ('•,�I�I- I�I),91 .s;`_t• '``
Date: USE OF -
EXISTING BLDG. - DEMOL' ❑ �,-I)L? �=1
Signature PLICANT. TEL.
FINAOWNER-BUILDER DECLARATION .(PRINT). (2IG+1L VA,O ,v� ) nao•243 lS'S5 DATE`
I hereby affirm that I am exempt from the Contractor's License
Law for the following redson,.(Section 7031.5, Business and FINAL,
Professions Code): PRESENT By
BUILDING
❑ I, as owner of the property, or my 'employees with ADDRESS 2 _"' i "•'
wages as their sole compensation,will do the work and
the structure is not'intended or offered for sale(Section LOCALITY
7044,Business and Professions Code.) MOVING TEL. ,�� o2�J/gL
CONTRACTOR NO, {, e"•! ""{
❑ I, as owner of the property, am exclusively.contracting . ': f w _,,• ,,`::
with licensed contractors to construct the project (Sec-
ADDRESS
tion 7044, Business and Professions Code.
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH =' i�r•Ir` ,€!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
Lender's Name P.L
LDMA Ref. # '�!L
P.C. Fee$ Permit Fee d �/
3 Lender's Address
I certify that I have read this application and state that the Issuance Fee LDMA P/C#
above information.is correct. I agree to comply with all County Investigation Fee.0 ��/ordinances and State laws relating to, building construction, Total Fee 4o LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
3 Z SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Applicant or Agent Date