HomeMy Public PortalAbout4958 GLICKMAN AVE_Building__ WC, -NP.ENSATION DECLARATION
I hereby affi°r have a'certificate of consent to self f
insure, or a cei ` -::;z of Workers' Compensation Insurance, A P P L I CJ�' ON FOR BUILDING PERM
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No:�22. LIZ
—CLTy G-L �t,GJ
❑ rn
BUILDING
Certified copy is hereby furnished.: FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDING �Lq
tion department. ADDRESS �j GILII/1/�N /�Ol) 1 `C✓� [y•(AG(y� /1AtJ. "on,
CITY`T 'U( ZIP3tJ LOCALITY L-C- CiLZY
Date �" Applicant NO. OF BLDGS. NEAREST -
CERTIFICATE OF EXEMPTION,FIR ' SIZE OF LOTf�dN�7b NOW ON LOT\//`^Ai CROSS SL L/ J"LO S!h'
COMPENSATION INSURANCE ASSESSOR i
(This section need not be completed if'the'permit is for one TRACT5C7C70� BLOCK LOT NO. MAP BOOK �S PAGE15 PARCEL 3
hundred dollars ($100)-,or less.) TEL. USE ZONE MAP l'u�/�7
OWNERGj"r e, V NO. ?s�Z NO. �7 41 L��.
1 certify that in the performance of the work for which this 'SPECIAL _
permit is issued, I shall not employ any,person in any manner ADDRESS Gi �WG�-- p�j "' • CONDITIONS 0
so as to become subject to the,Workers'Compensation.Laws. O
cITY L �N L ��✓ ZIP QUO 'i U
Date Applicant ARCHITECT OA405TEL.'
-DISTRICT GROUP
y 'TYPE FIRE PROCESSED,BY O
NOTICE TO APPLICANT: If,:after making this,Certificate of ENGINEEPC�ULDb �L NO 13 CONST. ZONE- U
Exemption,.you should become'subject.•to the Workers' `j,®8 P' 3 w
Compensation provisions of the Labor Code, .you must forth- ADDRESS �Peril `7 trl;Q OMI a-
with comply with such provisions or this permit shall be s TEL. STATISTICAL CLASSIFICATION APL CONDO. Z' ,
deemed revoked. CONTRACTOR p►J J , . NO. - —
LICENSED CONTRACTORS"DECLARATION LIC. CLASS NO. ®O DWELL. UNITS_
I hereby affirm that,Iam licensed under provisions of Chapter 9 ADDRESS d v , !- CdA+O(NO. &'70
: SEWER MAP
(commencing with Section 7000)of.Division 3 of the BusinessLIC.
r'� ,-,^•,�••-'." •
$t � P�AV ,I?(l3 C- a.
and Professions Code,and my license is in full force CIN CLASS and effect. BK. L PG.S L . rs:_• V94'�IDATION
SQ. FT.' NO. OF NO. OF CHECK' —
License Number 7d q7 > Lic:.Class SIZE �j() STORIES i FAMILIES ONE �f�i s-C
_ VALUATION .
Q_Q DESCRIPTION OF WORK NEW $ /7-3, 0�i O O` } lit
�i-
ContractoA�r O� � at 3`(' 11 rr�-- Z �y _ `
❑I am exempt under Sec. �® �pN ,� ADD ❑ ► f€ HL L�
ALTER ❑ __•ss -
B.&P.C: for this reason ;
, REPAIR ❑
'Date: USE OF.
XISTING BLDG. IDE OL ❑
Signature PPLICANT... TELT 6 FINAL
(PRINT)9=RAC-I- V 0 I PJPCA(r,,L NO��(v2 I�G� y
OWNER-BUILDER DECLARATION _ DATE-
I hereby affirm that lam exempt.frorri the.Contractor's License �y6' ++ _
ADDRESS 1'1LI C7• C LoW�ry 41� Ls��
Law for the following reason`(Section 7031.5, Business and FINAL z 'l
1 AN,Slly.r_;
Professions Code): PRESENT ByBU LDING
;
❑ I, as owner of the property, or my employees with ADDRESS _ i f _
wages as their sole compensation,will do the work and a� y�
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.)' MOVING TEL.
CONTRACTOR NO. �jy� s 1 " ,
❑ •I, as owner of the property, am exclusively contracting \ ,t
with Iicensed.contractors to construct the project (Sec- `)11 '
ADDRESS _• "'s a
Tion 7044,.Business and Professions Code.)_
REQUIRED TOTAL SETBACK FROM EXIST. ;"j `1•;';
CONSTRUCTION LENDING AGENCY SET BACK YARD. HWY PROP. LINE WIDTH „•.''` i�r. °'="-`
I hereby affirm that there is a construction lending-agency#or FRONT
the performance of the work for which'This permit'is issued P.L.
SIDE• ,' r•. .
(Sec. 3097,'Civ. C.). t:
P.C. t. _
L'ender's Name, .=,
LDMA Ref. # _ _. ...
m P. Fee$. /Z/-'!� Permit Fee
Lender's Address
f ,
"a I certify that I have read this application and state that the Issuance Fee of LDMA P/C#
o °
above information is correct. I agree to comply with all County Investigation Fee
8 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.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si Lure of•Applicant or Agent Date