HomeMy Public PortalAbout4962 GLICKMAN AVE_Building__ WO _ APENSATION DECLARATION {
insure,boroafcerti icc,ie of Wo ke s'tCompensat on Insuran elent to f A P P L I,C, _T .6 O N FOR BUIL®I N G P E RIVi
or a certified co y thereof Sec. 3800, Lab. C.)
Z� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. � Corc4pany SLG _I= U-'>
El Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
riul ADDRESS
Certified copy is filed with the county building inspec- BUILDING., r
tion department. ADDRESS 2 ca 4c v V �f 1• t�rj(�Z -IGl�JV1�� C,0 IJ
Date ?Applicant tZ>r�7 '-� arY" EI�I - GtT`'r zIP Gii � LOCALITY -rC-mt.G GtT
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM ORKERS' SIZE OF LOT e_-01000 NOW ON LOT ./ 1a.N CROSS ST. L-A- IZ-5A
COMPENSATION INSURANCE ASSESSOR ^�
(This section need not be completed if the permit is for one TRACTt^_ 0(4>& BLOCK LOT NO. MAP BOOK �� PAGE PARCEL��
hundred dollars ($100) or less.) TNOEL•
7 �,��y I Ili r�. 11 �D� { USE ZONE MAP
OWNERet
1 certify that in the performance of the work for which this LLQ- NO.
permit is issued, I shall not employ any person in any manner ADDRESS `�, r +r' jOLj -2- SPECIAL >_
CONDITIONS EL
so as to become subject to the Workers'Compensation Laws. O
CITY 7S.N&FLrVS ZIP p0
Date Applicanta ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If,. after making this Certificate of ENGINEER Gi�tJ G �- NO.U? � ° CONST. ZONE
Exemption, you should become subject to the Workers' I G� S Q -� ✓ U
Compensation provisions of the Labor Code, you must forth- ADDRES 6� 1-���'+ rVjc�fA
with comply with such provisions or this permit shall be _ TEL. � STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR r-C ,4,i-� NO. <d'� e ✓ z
O
LICENSED CONTRACTORS DECLARATION 1 LIC. CLASS NO. DWELL. UNITS Y
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS D ? b T p � O O. ZE _ 1 1
(commencing with Section 7000)of Division 3 of the Business SEWER MAP 15 i
/Z� C.
and Professions Code,and my license is in full force and effect. CITY :5�1..1 CLASS BK.I- PG.! ;",l-VALIDATION
SQ. FT. NO. OF NO. OF zz CHECK -- -• +--•
License Number F70 !�7ALLic. Class SIZE 50 ISTORIES FAMILIES 1 ONE
VALUATION
NEW
F � x-12 -
ESCRIPTION O WORK E� -
i-
o G- - L-,a•IJ �- ,
sc
3
=x
Contractor Date $ Poo.
I ij ix_ _ a ( _
ADD ❑ �
❑I am exempt under Sec. OMEWOMmi 1_FL"'
ALTER ❑ -
B.&P.C. for this reason $ i¢+�r
REPAIR ❑ _._
Date: a USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. '
g PRINT �P �- vAN W FINAL II-1 "6_;r'=i a =.,
OWNER-BUILDER DECLARATION \n, I L FGI'{�1, NO'L��i Cal�BI7 SS DATE Z� ` '
I hereby affirm that I am exempt from the Contractor's License Vk t
Law
for the following reason (Section 7031.5, Business and ADDRESS LC�4/vE'{- 0v L� FINAL :.
Professions Code): I PRESENT By R T
❑ I, as owner of the property, or m employees with BUILDING
P P Y, YADDRESS n r.
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY _g
7044, Business and Professions Code.) MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to,construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) y.(,.'
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.
(Sec. 3097, Civ: C.). SIDE
P.L:
Lender's Name
LDMA Ref. # - =t
� P:C. Fee$ � '-' Permit Fee So / -•.-• _- - h;i"; - --
Lender's Address �f,
o I certify that I have read this application and state that the Issuance Fee �7 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 �. 6a LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
a
3 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ure of Applicant or Agent Date