Loading...
HomeMy Public PortalAbout5002 GLICKMAN AVE_Building__ WC';:'ii '_')APENSATION DECLARATION insure,hereby cert�:,te of Workersve a rtCampensat Coificate of mpensationnt to AP P L I C : O N FOR BUILDING PERM: ora certified copy thereof (Sec. 3800, Lab. C.) 3 O� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Nd. f Company' STLI'T� T=USJ-P BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec-" BUILDING 002 �9 G tion department. ADDRESS r 1�� (tMA� �j �I�1/1/1/�1� Date Applicant CITY�rI P(r� �T ZIP�I �® LOCALITY -M Lam. e-A NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROI WORKERS' ' SIZE OF LOTCAODO NOW ON LOT CROSS ST. LA- COMPENSATION INSURANCE ASSESSOR (This section need not be completed if'the permit is for one TRACTCJOU(pC�3 BLOCK LOT NO. MAP BOOK �qS PAGE 1 PARCEL hundred dollars ($100) or less.) TEL USE ZONE MAP r� �7 OWNER!! ' I OF-V NO2I?j(OZ r9S� NO. !Y7 7' —i 3 certify that in_the performance of the work for which this 1 v- Z SPECIAL a permit is issued, I shall not employ any person in any manner ADDRESS � L � CONDITIONS so as to become subject to the Workers:Compensation`Laws. O CITY V� ZIP qrr© U Date Applicant ARCHITECT O TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE, TO APPLICANT: If, .after making this Certificate of ENGINEERS LJP& SOS NO'.M CONST. ZONE F- Exemption,:. you should become, subject to the, Workers' � S QZ� fJ � �/ w . Compensation provisions of-the'Labor Code, you must forth ADDRESS ice' v r- �, a with comply with such .provisions or this permit shall be TEL P STATISTICAL CLASSIFICATION APT. COND j Z deemed revoked. CONTRACTOR `� GO NO. F��O V _ LICENSED CONTRACTORS,DECLARATION UC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions'of Chapter 9 - ADDRESS44 OF !:';. 6S5k/J !tie/G-' NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. Y CITY Sds.iJ. Gysgls/� CLASS �' BK. L PG. �- , 1FALIDATION _ and Professions,Code,and m license is in full force and effect. -,�- SQ. FT. NO. OF NO. OF CHECK wf��•= License Number S 7d �� Lic. Class SIZE STORIES i FAMILIES ONE I l DESCRIPTION OF WORK (�i,�I l NEW Int VALUATION Contractor's ©f, Date ✓?_�.g._�y Ute' a O• e'!,Iii =i r =. _. ADD.. ❑ $ / �� ❑I"am exempt under Sec: q km PIP C�0 PJB ALTER ❑ BAP.C. for this reason ��� REPAIR ❑ $ :CHANGE n i lwl Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT G TEL. (/�/�� rr (PRINT)af°'F�7�' NO WL I�'�`7 FINAL Irl I.r(.ti. - _Ef1I/=t;�} OWNER-BUILDER DECLARATION 11 /� DATE I hereby affirm that I am exempt from the Contractor's License t. � f y � Law for the following reason (Section 7031.5, Business.and ADDRES � 1�' It 'O a FINAL Ll Professions Code): PRESENT' - By ~ - ` BUILDING .E1 1, as owner of The property, or my employees with N ADDRESS y _ wages as their sole compensation,will do the work and LOCALITY d +„•f _ .C the structure is not intended or offered)for'sale(Section 7044, Bus iness'and Professions Code. MOVING. TEL. CONTRACTOR NO. �y7 ❑ I, as owner of The property, am exclusively contracting _ with licensed contractors to construct-the project (Sec- ADDRESS tion 7044, Business and Professions Code.,) 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 _;a o__ The performance of the work for which,this*permit.is issued P.L. (Sec. 3097, Civ.'C.). SIDE P.L. Lender's Name, !- q �+) H+. I * t . -'77 OCJ Ala I,/ d / LDMA Ref. # V' P.C. Fee$ . Permit Fee , Lender's Address o I certify that I have.read this application and state that the. Issuance Fee a 7, LDMA P/C# o' 8 above information is correct.I agree to comply with all County Investigation Fee, n 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 9 P� SEE REVERSE FOR EXPLANATORY LANGUAGE Sig re of'Applicant or Agent Date