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HomeMy Public PortalAbout5000 GLICKMAN AVE_Building__ WC.. ":MPENSATION DECLARATION insure, or a ct. a of Workers' Comtpensation ent Insuran eto self A P P L I C=T .� O N FOR BUILDING PERM., or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.`x7"30 Company ;�71 Z TrJ rJ� BUILDING Certified copy is hereby furnished. . . FOR APPLICANT TO FILL IN ADDRESS 9 Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS �!©�� UViGf-���'N �T. p ZP(:> &t_k"<,^AA0 Date 3`� � Z Applicant CIN i-M T`f ZIP1 60 LOCALITY _TLA4 LAE C4 NO. OF BLDGS. NEAREST ^ CERTIFICATE OF EXEMPTION F M WORKERS' SIZE OF LOT coP o NOW ON LOT t!1`-gyp NT CROSS ST. �./-� (Z.Q�✓� COMPENSATION INSURANCE ASSESSOR D (This section need not be completed. if the permit is for one TRACTQ(�? BLOCK LOT NO. MAP BOOK PAGE ` PARCEL hundred dollars ($100) or less.) TEL. OWNER L f USE ZONE MAP / Z7 3 -,TP � QTL G% '� N0!74 J t`p�✓ L✓S� NO. I certify that in the performance of the work for which this { /,-- Z SPECIAL } permit is issued, I shall not employ any person in any manner ADDRESS /-�{ E r 'C7� CONDITIONS n.. so as to become subject to the Workers' Compensation Laws. � ,�' O CITY Lf�/ [.x-[�V� ZIPU Date Applicant ARCHITECT OR TEL. � NOTICE TO APPLICANT: If, after making this Certificate of ENGINEERG W �'� NO;?,1?� i c DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption, you should become' subject to the Workers �I t g _� CONST. ZONE V Compensation provisions of the Labor Code, you must forth- ADDRESS lO 1 W for 11C-A. y ___ a with comply with such provisions or this permit shall be t NO STATISTICAL CLASSIFICATION '''?Pf.' CONDO. Z deemed revoked. CONTRACTOR -{' LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. 00 DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS /f o 4 3Ao IG NIO. O G' EWER MAP s L 1's u3 (commencing with Section 7000)of Division 3 of the Business f� LIC. S , j� /J <3 /�i��C3 C� CLASS and Professions Code,and my license is in full force and effect. CIN BK. L- PG.S ? ('=YALIDATIO�V j _ SQ. FT. NO. OF NO. OF CHECK License Number L✓7u �� Lic. Class SIZE Ifo STORIES FAMILIES ONE _ VALUATION NEW - �Q DESCRIPTION OF WORK f $ f 3� �C7 �C .•fjn:`i _ _ a Contractor ��J Date 3-1 �- 9� � ,�' 1� L^`"W°v ❑I am exempt under Sec. Q� / t �pj�t7o ADD ❑ ALTER ❑ 'ty t :i_,• tLti, B.&P.C. for this reason $ REPAIR ❑ - --• - Date: USE OF !t__:% EXISTING BLDG. DEMO ❑ Z r: E Signature APPLICANT p� TEL. g OWNER-BUILDER DECLARATION \ (PRINT) � rIG•VANd �l/No2I?� (per' lSSs FINAL I hereby affirm that I am exempt from the Contractor's License DATE �G Law for the following reason (Section 7031.5, Business and ADDRES '�'1-�vJmw12 4fO'g L)A' FINAL Professions Code): ERESENT By I, as owner of the property, or my employees with BUILDING� ADDRESS wages as their sole compensation,will do the work and a i O " ? 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. with licensed contractors to construct the project (Sec- ADDRESS - tion 7044, Business and Professions Code.) - -` CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY IRED TOTAPROPAINEFROM 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. !� e� / P.C. Fee$ / Z /r Permit Fee ���• LDMA Ref. # - Lender's Address 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. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. a , SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Applicant or Agent Date