HomeMy Public PortalAbout4807 HALLOWELL AVE_Building__ WORKERS'COMPENSATION DECLARATION
e insure borairrn afcerfifcate o QWorkersriificate Compensat on ensurancef of consnt to sel
APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
PY Y ADDRESS
❑ Certified copy is filed'with the county building inspec- BUILDING
tion department. ADDRESS /p LL � '�;4 L L f rL
Date Applicant CITY T`, d/ _ G�/. / ZIP LOCALITY �'
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST `C,G
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not-be,completed if the permit is for one - �r ASSESSOR �)
hundred dollars ($100)or less.). TRACT �<^,(� / BLOCK LOT NO. MAP BOOK' 3 3 d PAGE.`Y",1_ PARCEL
/e r .TEL. USE ZONE MAP
OWNER P� / t=./ -J/_`.z-�NO. � `J!`
I certify that in'the performance of the'work'for which this NO. -t
permit is issued, I shall not employ any person in any manner P� , SPECIAL
sd as to become subject to the Workers'Compensation Lows. ADDRESS S X L. f7 G4.� L G. T��_. CONDITIONS �O
Date J—C— APPlicant CITY ( " C j ZIP 917..
f. ` 111)
NOTICE TO APPLICANT- If, ofte making this Certificate of ARCHITECT OR !a TEL.- DISTRICT GROUP TYPE FIRE PROCESSED BY _
ENGINEER NO. CONST ZONE
Exemption, you should become' subject to the Workers' i�� /�� tu
tu
13
Compensation provisions of the Labor Code, you must.forth- ADDRESS �i
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO: c�
deemed revoked.: �
CONTRACTOR - `J ,t:- NO.
LICENSED CONTRACTORS DECLARATION LIC; CLASS NO._DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(cammLIC-
Pr
IC
encing'with Section 7000)of Division 3 of the Business and SEWER MAP
.-
Professions.Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT- NO.OF NO.OF CHECK
License Number Lic.Class SIZE 6 STORIES FAMILIES ONE
VALUATION 00
Contractor Date
DESCRIPTION OF WORK NEW $ a 00
0 —
s�
ADD ❑ 3 Jq
❑ 1 am exempt under Sec. ALTER ❑ , # �: ¢g
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF EXISTING BLDG. I DEMOL ❑
Signature APPLICANT �, . _ FINAL ��
OWNER-BUILDER DECLARATION PRINT) ��. - n,:&i-__D . Y t DATE �' �^
I hereby affirm that I am.exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS IF
Professions Code): PRESENT // o o BUILDINGU
❑ I, as owner of the property, or my employees with ADDRESS At 1t () 11 1 `
wages as their sole compensation,will-do the work andLOCALITY � v (T '
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). MOVINGTEL.
I, as owner of the property, am exclusively contracting CONTRACTOR (:.�/v C.- NO.
with licensed contractors to construct the project (Sec-.
ADDRESSL '66
tion 7044, Business and Professions Code). ;2 4 0 9'
REQUIRED TOTALSETBACK FROM EXIS ff o .o o a 0
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT . 6o
75
the performance of the-work for which this permit is issued P.L. -` 0 0 6 6 7:5=
(Sec. 3097, Civ. C.). SIDE Q v
P.L.
o Lender's Name .2 9—8'6
o r/) '92 t LDMA Ref. # ,
- - - P.C. Fee$ J(/ Permit Fee-
- Lender's Address ~
Ot s
I. certify that 1 have read this application and state that the Issuance Fee jiTiJ-� LDMA P/C# -
above information is correct. I agree to comply with all County Investigation Fee �,
m ordinances and State laws relating to building construction, k0t� �+°lr 5 LDMA Perm. #
v and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of pp can tor Agent - Date -• - '- - •�
l