HomeMy Public PortalAbout5016 GLICKMAN AVE_Building__ W,;''.! t"OMPENSATION DECLARATION
insure, or°a c i,..ae'af Warke srt have a tCampensation lnsurancef A P P L I I'._, ': ION FOR BUILDING P E RM 1.1
or a certified copy thereofSec.'3800, Lab. C.)
122-30COUNTY OF LOS ANGELES. BUILDING AND SAFETY
zQ
Policy No. / Cr/ipany
BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN' ADDRESS
IG7� Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS CJ�1� '(1L �( -gGNUTE S oIlo
Date—, Applicant CITY _ (. G ZIP 4! "OO LOCALITY
NO. OF BLDGS. NEAREST
CERTIFICATE OF.EXEMPTION WORKERS' SIZE OF LOT Ce*_'70 NOW ON'LOT V/ CROSS ST.
• COMPENSATION INSURANCE
This section need not be.com leted_if the 57CX=1`r- ASSESSOR ( r
( p permit is for one TRACT�J�-'�l�/ BLOCK LOT NO. MAP BOOK $J gJ PAGE �1 PARCEL
hundred dollars ($100) or less.) TEL.
OWNER Ci 1IJ 97EM+' NO.IA (rj •�C USE ZONE MAP• JJ s 7e
I certify that in the performance of the work for which this . NO. �� /7
permit is issued, I shall not employ any person in any manner ADDRESS. �a e IZ- 14o `' CONDITIONS �• O
so as to become subject toahe'WI SPECIAL
orkers'Compensation.Laws. ^ U
- . ' - - CITY�S �°�C� 'i � ZIP 00
Date Applicant ARCHITECT OR- I-' �L s TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER 8�!-tjOt4 f a0� NO�{� j DISTRICT .GROUP TYPE FIRE PROCESSED BY
CONST. 7gNE
Exemption, you, should become subject to, the Workers' p U
Compensation provisions of.the Labor Code,you•must forth- 1 ADDRESS �Ot.IICA_ �a a
®
with comply with such provisions or this permit shall be
TEL STATISTICAL CLASSIFICATION APT. CONDO.
u7
deemed revoked. CONTRACTOR 'T'h' �� eO NO. _ Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS =
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1103S. 6 .6 1y- 't-42
LIC. SEWER MAP Ht 1tl
(commencing with.Section 7000)of Divin full of the Business C -S p4gLIDATION
CITY �✓�/.J NO. 0 jI�' r�G�. CLASS BK. 'PG. �
and Professions Code,.on8 my license is in full force and effect. ,_.
_7 ?-� SQ. FT. NO. OF NO. OF CHECK
License Number's ,! 6l /� `-Lica Cldss' SIZE. C7?� STORIES FAMILIES ONE
_ i / VALUATION
Contractor rd/_J Date 1� �/ �-�Z DESCRIPTION OF WORK Urll �j LA�hI&A NEW � ; "�, ,E€ •�I
❑I am exempt under Seca tJ ®.GoNf>a ADD ❑ t..,
ALTER ❑ e'`'S`' '•`3 n
REPAIR El S, CCA#(t3
BAP.C. for this reason sl-;i
Date: USE OF
EXISTING BLDG. DEMOL El
Signature PPLICANT
(PRINT) I"a \I^
\OU FINAL
OWNER-BUILDER DECLARATION + L `' tiC-10!_01'01w
I hereby affirm that I am exempt from the Contractor's License DATE
ADDRESS -� I-�wEIL ' IoS 1ps�cvv�i `t°;�:.1 i �i'1 :_,:.,_
Law for the following reason (Section 7031:5, Business and - '\1 FINAL
Professions Code): \� PRESENT . ;i ,, By
BUIL;DIttG
❑ I, as-owner of the property ,or my employees with t�D��2E5$.: 1 Q
wages as their sole compensation,will do the work and;
the structure is riot 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 c'•a-
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINE WIDTH -
I hereby affirm that there is a eonstruchon_lending agency for FRONT " >> IAtjr ; r
the performance of the work for which this permit is.issued
P. x.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name.
d // LDMA Ref. #-
P.C. Fee$ / / Permit Fee
3 Lender's Address „_._ " _ ,
o I certify that I have read this.application and state that the Issuance Fee a�.7S LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee`
0 ordinances and State laws relating to building construction, Total Fee 11
T -0Of LDMA Perm. #
a and hereby authorize representatives of this County to enter
Upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sit re of Applicant or Agent Date