HomeMy Public PortalAbout4836 HALLOWELL AVE_Building__ r WORKERS' COMPENSATION DECLARATION
to sf
insurebor a certifcatte•of Workers' Comipensatonent Insuran e, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
cj
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS GCt--
❑ Certified copy is filed with the county building inspec- BUILDING ' _
tion department. ADDRESS �` / 1I�
CITY' Y�1 . GA ZIP LOCALITY
Date Applicant NO. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT NEAREST
CROSS ST.
COMPENSATION INSURANCE ' ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars($100) or less.) ' �vv USE ONE MAP �1
OWNER Q(
I certify that in the performance of the work for which this ;'�,�,,��� ) NO.
permit,is issued, I shall not employ arty person in any manner ADDRESS �� �'��/�7 W SPECIAL a
!!! CONDITIONS
so as to become subject to the Workers Compensation Laws. 0
CITY D 1V1� IP
Date Applicant ARCHITECT O �� EL. TYPE
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER DISTRICT GROUP CONST. FIRE ROCES ED BY Q
Exemption, you •should become subject to the Workers' _ V
w
Compensation'provisions of the Labor Code, you must forth- ADDRESS (SIV �e cJso 0-
with
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIF CATION APT. CONDO. Z
'deemed revoked. CONTRACTOR NO. _
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
LIC. SEWER MAP-
(commencing with Section 7000)of Division 3 of the Business � .�= -
and Professions Code,and my license is in full force and effect. . CITYE- CLASS BK. PG. f r•-rl/ALIDATION
SO. FT. NO. OF NO. OF CHECK
SIZE I STORIES FAMILIES ONE t•[i•1•e e4
License Number lic. Closs �• --
VALUATION �t,� ?J �'• a=•Y
Contractor Date DESCRIPTION OF WORK ADD ❑ $SCJ Q � SO ITEMS
❑1 am exempt under Sec. i �y0 q
er ALTER L J �( /,,/°� ► TOTAL AL ...5 3'SLP - •a 3
B.&P.C. for this reason REPAIR ❑ $ -7 OJ F.31` "'`� CHECK J oh•
Date: USE OF DEMOL ❑
EXISTING BLDG. I CHANGE
APPLICANT Aw '� TEL !�•��i�r�� - �Iii
Signature PRINT `�/$ TEL 0 FINAL -
OWNER-BUILDER DECLARATION /. DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESSkq �'/1 0000-0001 i 23/90
Law for the following reason (Section 7031.5, Business'and L •
Professions Code): PRESENT
By
13 3' 1 AM :46
❑ I, as owner of the property, or m em to ees with BUILDING
P P Y� Y P Y ADDRESS
wages as their sole compensation;will do the work and
the structure is not intended or offered for sale(Section
7044, Business and Professions Code.) LOCALTY MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. J,
with licensed contractors to construct the project (Sec- ADDRESS 1
tion 7044, Business and Professions Code.) f`
CONSTRUCTION-LENDING AGENCY "SETOBACKK YARD HWY TOTAPREOP. LINE WIDTH,
WIDTH.
I hereby affirm that there is a construction lending agency for LInv*
the performance of the work for which this permit is issued
(Seca 3097, Civ. C.).
Lender's Name.
m
Permit FeeLDMA Ref. #
Lender's Address1 certify that I have read this application and state that theIssuance Fee LDMA P/C#
above information is correct. I agree to comply with'all County ee
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
o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date - -