Loading...
HomeMy Public PortalAbout5006 GLICKMAN AVE_Building__ Wr" )MPENSATION DECLARATION insureboraa cd,; e of Workers' Compen ation Insurance, APPLI : -. ''ION FOR BUILDING PERMI, _- or a certified copy thereof (Sec. 3800, Lab. C.) lzz ©ZCOUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company 57Z%E 41J k�� BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS rrO06 CITYTE-MPLji 'GiT r ZIPI LOCALITY !�A4 Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FR WORKERS' SIZE OF LOT00PJCi` NOW ON LOT l( A� CROSS ST. ( ln- P7 oS,A COMPENSATION INSU ANCE (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK D5 PAGE �I PARCEL ASSESSOR hundred dollars ($100) or less.) i TEL. OWNER�iT��i C! L ,C7R V�, TEL. 3 tP0 rj�j USE ZONE NOP I certify that in the performance of the work for which this 1 '' '' (� ` permit is issued, I shall not employ any person in any manner ADDRE S, L�rl✓ 1`4G7fj 9 SPECIAL so as to become subject to the Workers'Compensation Laws. �, CONDITIONS GCS O CITY �1 L,L✓� ZIP a[�2� I U Date Applicant s ARCHITECT OR I TEL. NOTICE TO APPLICANT: If, after making this Certificate of ` ENGINEER G-UNX:, o� �' DISTRICT GROUP TYPE FIRE PROCESSED BY NO. � CONST. -ZONE 0 ft Exemption, you should become subject t the Workers' t� � jL �Ud �� w Compensation provisions of the Labor Code, you must for 11 ADDRESS i 1r U !� n- with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed.revoked. CONTRACTOR (,MX'�O (y NO. — p Ci Z LICENSED CONTRACTORS DECLARATION I LIC. CLASS NO. ® � DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS//O. S: 5�N '53A&P-1V O•S U74 - (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY sd e;.-" ,a-i 6 — CLASS BK L' PG.� , VAiIDATION E r�7 SQ. FT.' NO. OF NO. OF CHECKC. License Number_ ✓ /D 7� Lic. Class SIZE "2,0-70 STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK ,l NEW I j-;`':'i ,� Contractor c) Date `I Q—�� "� �G' $� � j dU-C� ADD ❑ ❑I am exempt under Sec. - - :i) r, ALTER ❑ ;- (::- f B.&P.C. for this reasonREPAIR. ❑ - Date: USE OF EXISTING BLDG. DEMOLi ❑ Signature APPLICANT. + TEL (PRINT) �L� �bt� C(�j-F NOV.6/s- (pl Cj FINAL OWNER-BUILDER DECLARATION DATE - I hereby affirm that I am exempt from the Contractor's Licensez_ Law for the following reason (Section 7031.5, Business and ADDRES ���1` ./�� FINAL Professions Code): PRESENT By < BUILDING ; ❑ I, as owner of the property, or my employees with `j DDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) f� MOVING TEL. ❑ I, as owner of the property, am exclusively contracting \�\� CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) CONSTRUCTION LENDING AGENCY SET BACK YARD HWY IRED TOTAPROPAINEFROM WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. - (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name LDMA Ref. # P.C. Fee$ p / Permit Fee / �i5' -:"i_ Lender's Address o I certify that I have read this application and state that the Issuance Fee 1 LDM 1 A P/C# 0 above information is correct. I agree to comply 8 with all County Investigation Fee / a ordinances and State laws relating to building construction, Total Fee / �O LDMA Perm. # and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. a 3 SEE REVERSE FOR EXPLANATORY LANGUAGE 9—p2 Sign a of Applicant or Agent Date