HomeMy Public PortalAbout4956 GLICKMAN AVE_Building__ WC i ::7MPENSATION DECLARATION '
insure,hereby
,,-
aa cc' �._,ae of Workers'lCompensation ificate of eInsuran ent to lf A P P L I LI- _� ION F O.R BUILDING PERM►_� _
or a certified copy-thereof (Sec. 3800, Lab. C.)
Policy No.l�� C-14ny si/AT6 �� COUNTY OF LOS ANGELES BUILDING AND SAFETY'
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING ,,, �u LILM�IJ GT `6ral S (, C,L v
tion department. ADDRESS rLL�ryL t j c-0 (L
�. CITY G ZIP 'I[ O LOCALITY T ,AA L-l: CA r
Date Applicant NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FR 1 WORKERS' SIZE OF LOT�jOIJG'O NOW ON LOTV�1- CROSS ST. L-,A, l�
COMPENSATION INSU NCE ASSESSOR
(This section need not be completed if the permit is for one TRACT ZSO0Co� BLOCK - TOT NO. /NAP BOOK PAGE �� PARCEL
hundred dollars ($100) or less.) 11 r ' TEL'AA''?/� a `� USE ZONE- MAP
OWNE Cy L_ ��vv, NO.rT)tY d5s5 NO. �7
I certify that in the performance of the work for which this 1 - y
permit is issued;I'shall'not employ any person in any manner ADDRESS Lov✓ 1IO�j �L�� SPECIAL _ a
CONDITIONS
so as to.become subject to the Workers'Compensation Laws. � Q O
CITY tJ(»L.� ZIP fOo'�I. U
Date Applicant ARCHITECT OR TEL 0
NOTICE TO APPLICANT: If, after makingAhis Certificate of ENGINEER G1I1JP61 A-C-10Z-- NO, .- DISTRICT GROUP TYPE FIRE PROCESSED BY
CONST. ZOI�F; �
Exemption, you should become subject to, the Workers' \ Q w
Compensation provisions of the Labor Code, you must forth- ADDRESS�ft dr!* p- f4OM�A `� `3 , - a
P P y st?'[ N
with, comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTOR NO. -dV® ®p , ~? �`. Z•
LICENSED CONTRACTORS DECLARATION
LIC. CLASS NO. DWELL. UNITS__L
° =
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS t'I 193. $. ✓�".J a NO. , -70 m=
(commencing ) g SEWER MAP
commencin with Section'7000 of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY /�, �/ !s/ CLASS BK. PG. S YALjDATJON
SQ. FT. NO. OF n NO. OF CHECK
License Number O • .q Lic. Class SIZE 407 STORIES v FAMILIES ONE
7. ` 7
t� VALUATION �'E�a�
ESCRIPTION OF WORK I ` �, NEW LrEp 3} [r °
Contractor G Date ,3�-fy-�2 $/7-3 DC�a,
ADD ❑ I n., ° [
❑ 1 7-
1 am exempt-under Sec. aIED ��Od�DO ,
ALTER ❑ _..e,
B.&P.C. for this reason $ Iz'-r:
REPAIR ❑
Date: USE OF
EXISTING BLDG. DEMOL ❑ •H N't• -
Si nature APPLICANT TEL
Signature-,- (PRINT)fFPIG IL vANW Czt SEL NOZ}'7(p I j jS FINAL
OWNER-BUILDER DECLARATION _ DATE ` Z �9y �--
illi i€ 3 ''i::;;•,
I hereby affirm that I am exempt from the Contractor's License = � 1_-'.i:;.:1 �-rte; ;y
'\ ADDRE GJ (pW '��L7 �f I-a
Law for the following reason (Sect ion'7031.5, Business and FINAL
Professions Code): (`� PRESENT By _._.., --
BUILDING j
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the-work and - , � -[,•[-:�r
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. y1
❑ I, as owner of the property., am exclusively contracting CONTRACTOR NO. 7T1 •-:,:
with licensed contractors to construct the project Sec- R :4 '
P I ( ADDRESS =T
Tion 7044, Business and Professions Code.)
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. 1_•PI T3'tM
CONSTRUCTION LENDING AGENCY SET BACK 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.
(Sec. 3097, Civ. C.). SIDE _.."',.
P.L :..
Lender's Name, G�
P.C. Fee$ / /'�rD Permit Fee LDMA Ref. #
Lender's Address 7
o I certify that I have read this application and state that the Issuance Fee / LDMA P/C#
8 above information,is correct. I agree to comply with all County Investigation Fee -
d ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
3 f-
Lure of Applicant or Agent Date