HomeMy Public PortalAbout4960 GLICKMAN AVE_Building__ WC .; APENSATION DECLARATION
insure, or a ceri;..r r.e of Workers' Compensation Insurance, P P L I�_ - �I O N F O.R BUILDING PERM.
I hereby affil nave a certificate of consent to self _
ora certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES • BUILDING AND SAFETY
Policy J22,30 Z Ca pany :r,: STC_ _LJtJ�
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
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Certified copy is filed with the county building inspec- FADDRESSILDING
CD O C_4w6I�B�'Y1�p G l {(p0
tion department. QQ GC.�G �,P� •
Date a Applicant "Z— W1 , Gi T ZIP"I I lib LOCALITY ►lr M LL 64-TY
NO. OF BLDGS. NEAREST
.CERTIFICATE OF EXEMPTION FRWORKERS' SIZE OF LOT C-C>Nt:�D NOW ON LOT V CROSS ST. L/'1 I� 'A
COMPENSATION INSURANCE 7
(This section need not be completed if the permit is for one TRACT X70' ACO BLOCK LOT NO. IQ MAP BOOK ASSESSOF �� PAGE ! PARCEL J
hundred dollars ($100) or less.) TEL.
OWNER� /`� C, I NTL p��/� No :5 (pZ USE ZONE MAP
I certify that in the performance of the work for which this 2 NO.
permit is issued, I shall not employany person in any manner ADDRESS �j, �LD>yJ I@j 'Z SPECIAL a O
CONDITIONS
so as to become subject to the Workers'Compensation Laws. U
CITY ZIP GSI
Date Applicant ARCHITECT OR TEL.
.s DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, .after making this Certificate of ENGINEER ai4j ' I G NcoNST,./ ZONE (—
Exemption, you should become subject to the Workers' r, ® —� V w
Compensation provisions of the Labor Code, you must forth- ADDRESS Tis G��"A (`f{ot\IIG/, J 0-
with
with comply with such provisions,or this permit shall be II TEL. Q STATISTICAL CLASSIFICATION 7 APT. CONDO. Z
deemed revoked. CONTRACTORSC':oN �►�5— NO. �— O (� - _
LICENSED CONTRACTORS DECLARATION I LIC. 95 CLASS NO. 0 0 DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 t ADDRESS ;C� rJ _ NO. _ p
(commencingwith Section 7000 of Division 3 of the Business LIC. SEWER MAP
) ` CITY --, /J cloe02/G L• CLASS
and Professions Code,and my license is in full force and effect. � BK. L PG. S � VALIDA_TIOPI +
SQ. FT.. NO. OF NO. OF CHECK
License Number 1 Lica Class Ir'7 SIZE (p STORIES 'T�� FAMILIES ONE " "i i`
VALUATION =-u�9 16
Contractor�I= 1 DFJ Gv'1�vr Date `3 —I g —1 2 DESCRIPTION OF WORK LJ�'( (� 15 C, NEW $ /Z3 0D
�— ADD ❑ / 7 ► �`.:i';
❑I am exempt under Sec. ALTER ❑ '.`"' i
B.&P.C. for this reason REPAIR',❑ $ z
Date: USE OF
EXISTING BLDG. ' DEMOL'❑ .Jt i.1
Signature APPLICANT TEL. ,_
(PRINT) PICieIVA �N;zI4R20L (a 1��5 FINAL 1 ��
OWNER-BUILDER DECLARATION y DATE L
I hereby affirm that I am exempt from the Contractor's License 1 ADDRESS e-,. IA`,e� �Ip� �—•�`
Law for the following reason (Section 7031.5, Business andFINAL
Professions Code): PRESENT ByBUILDINGEl -
I, as owner of the property, or my employees with � ADDRESS �a
wages as their sole compensation,will do the work and I .c
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code.) ` MOVING TEL.
❑ I, as owner of the property, am exclusively contracting \ CONTRACTOR NO. `yyl
with licensed contractors to construct the project (Sec- !i,
tion 7044, Business and,Professions Code.) aDDRESS I
REQUIRED TOTAL SETBACK FROM EXIST. :t:__ -.•;y x•:
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.
(Sec. 3097, Civ. C.). \ SIDE
Y P.L.
Lender's Name
m 9 7 LDMA Ref. #
P.C. Fee$ "/% �LC/ Permit Fee (!• D l
Lender's Address "-"' �E' -
0 1 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 /
8 ordinances and State laws relating to building construction, Total Fee �. �(t� LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
3 SEE REVERSE FOR EXPLANATORY LANGUAGE
S gn re of Applicant or Agent Date ,