HomeMy Public PortalAbout4952 GLICKMAN AVE_Building__ WC:;I C:C)MPENSATION DECLARATION
ar°a !.,)have of Workers' Compensation ent to Insuran elf AP P L I�_-_: ION FOR BUILDING PERM-
insure, ;_
or a'certified copy ihereofLS tc. 3800, Lab..C.)
� •�3d>QI COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company E UI"��
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
. Certified copy is filed with the.county building inspec- BUILDING n
tion department. ADDRESS ,7 7_ 49
157— (,uC_V_MA" "VV
Date Applicant CITY'TEIn l6 GT ZIP i LOCALITY =�
NO. OF BLDGS.
CERTIFICATE OF EXEMPTION OM WORKERS' SIZE OF LOT GoNDO NOW ON LOT`/�`-C�+ C OSSSST.
COMPENSATION INSURANCE
ASSESSOR p
(This section need not be completed-if the permit is for one TRACT 00(00 I BLOCK LOT NO. MAP BOOK .PAGE PARCEL 3Z•
hundred dollars ($100) or-less.) TEL' �t� USE ZONE MAP �f ��?
OWNER � iN"fL NO. el161�i5 5 NO. `
I certify that in the performance of the work for which this
;permit is issued, I shall not employ any person in any manner ADDRES , �I Ion✓ —� CONDITIONS ' o_
so as to become subject to the Workers,Compensation Laws. O
CITY e, /aN� l `� zip �a 1 U
Date Applicant. ARCHITECT OR TEL. be
DISTRICT GROUP TYPE - FIRE PROCESSED BY: O
NOTICE TO APPLICANT: If, after.making.this Certificate of ENGINEERS L1N6 ®' � NO. 34 CONST. ZONE 1—
Exemption, you.should become subject to the Workers' �,®g /Z`3 U
Compensation provisions of the Labor Code; you must forth- ADDRESS I llfikS'C. tarAvinoNhA a
N
with comply with such provisions or.this permit shall be TEL. STATISTICAL CLASSIFICATION ;APT. JCOND�7_ Z
deemed revoked. CONTRACTOR 1S NO. f, 9 —
LICENSED CONTRACTORS DECLARATION LIC. CLASS No. O DWELL. UNITS I _
]'hereby affirm that I am licensed under provisions of Chapter9 ADDRESS l f Gid s@ NO• D 9
(commencing with Section 7000)of Division 3 of the Business LIC. p� SEWER MAP
CIN �A �.� i�/0 C_ CLASS -it t l
and Professions Code;and my,license is in full force and effect. BK L PG —]� VALIDATION
�''7 SQ. FT. NO. OF� NO. OF CHECK s i
License Number d 7� Lic. Class SIZE �✓� STORIES FAMILIES ONE VALUATION
. .. a f :=:1 Es
Contractor( tyj r_.104 Date 3 _-.'l 1� DESCRIPTION OF WORK °`1N� 1� LAN NEW Z .vac .D
❑1 am exempt under Sec.
Av�� ADD ❑ �� , `•'si�t)i '.,`o
ALTER. ❑
B.&P.C. for this reason REPAIR ❑ a
Date: USE OF
EXISTING BLDG. DEMO[ 0 Dt {1 t 1p(j "-;o
Signature APPLICANT _ ELL
OWNER-BUILDER DECLARATION (PRINT)F—W—``Y %IAO V)EVes TNO-Z8 10_13"qDATE _
a
I hereby affirm that I am exempt from the Contractor's License DDRES L.OI/`��h
Law for the following 'reason.(Section'7031.5; Business and. FINAL
Profess ions`Code)-:' PRESENT By• }, _s_
BUILDING
❑ I, as owner of theproperty, or,my employees with ADDRESS.
wages as their sole compensation;will do the work and p
the structure is not intended or offered for sale(Section LOCALITY73 1 c;
7044, Business and Professions Code:) MOVING,, TEL. /7
CONTRACTOR NO. `7�X +. 'i + =
❑
[,'as owner of the property, am exclusively contracting ;;; €: fi_.w -J0.
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 hereby affirm that there is a construction lending agency for FRONT
the performance of.the work for which this permit is issued P.L. I''i.ti _ "h
(Sec. 3097, Civ, C.).. SIDE
Lender's Name
P.L. X11"i
LDMA Ref.:#
P.C. Fee$ ! ' Permit Fee
Lender's Address
0 1 certify that I have read this application and state that the Issuance Fee LDMA P/C#
0
8 above information is correct.I agree to comply with all County Investigation Fee
N ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
a
` 7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sj ature of Applicant or Agent Date '