HomeMy Public PortalAbout4908 HALLOWELL AVE_Building__ WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I havecertificate of consent - self : B U 1 L'D I'N.G.-PERMIT
insur-e, or a certificate of Workers' Compensation Insurr _,q p.p L IC.AT 10 N- FOR -ance,
or a certified copythereof (Sec: 3800, Lab. C.) '
dgTO 484. 'lOga FTn - COUNTY,OF LOS,•ANGELES.- BUILDING•AND'SAFETY '
m anyWt=4i -'Prn p1 S J BUILDING ~_D
n Certified copy is hereby furnished. FOR APPLICANT TO FILL.-IN ADDREss' -
,`Certified copy is filed with the'county building•inspec- BUILDING
„'tion department., ADDRESS.'•, .=4.9.08'- Hailowe1'1:.- -LOCALITY - =+
NEAREST
Date 1 0 f 1 64R4Applicantl,ytle Roofing CITY ZIP - CROSS ST 6-U44 ) 11
CERTIFICATE OF EXEMPTION FROM,WORKERS'• NO.OF BLDGS ASSESSOR
COMPENSATION INSURANCE
SIZE OF LOT :NOW ON LOT 1 MAP-BOOK PAGE PARCEL
(This.section need not be completed:if,the permit is fog one USE-ZONE• MAP JJ'��
hundred,dollars ($100)or less.), �, TRACT _ BLOCK 6T NO {K/^( („ NO. V
TEL _ :SPECIAL• }
} I'.certify that.in the performance of the-work for which this OWNERP. ter• Mannin No 442-3591 CONDITIONS` n-
permit is issued; I-sholl.not employ,any person in any manner `• - DI TRICT GROUP TYPE FIRE PRO SSED BY U
so os to become's the Workers'Compensation,Laws,, ADDRESS 4908 Ha11OWe11-' �j' CONT/ ZONE
CITY.. -ZIP �io �/• �/1 �' O
Date Applicant 1� ' STATISTICAL CLASSIFICATION ;_ , APT. CONDO' : V
NOTICE TO APPLICANT: If, after making this Certificate of
ARCHITECT OR TEL
ENGINEER l NO. CLASS NO DWELL UNITS
Exemption,: you should become subject'to-the W-Fkers''
Compensation jirov,isions of,the Labor Code; you must forth- ADDRESS' = SEWER MAP + ,,r
with 'comply with•such' provisions or this-•permit shall be 4 I - - - _
deemed revoked:- '__ ;TEL BKr PG;
VALIDATION'
CONTRACTORL t1e Roofiri No.792-.5171
LICENSED CONTRACTORS DECLARATION '• LIC
I hereby affi�m'that'I'am Iicensed:under provisions of Chapter 9 ADDRESS - ANO VALUATION
(commencing with Section 7000)of Division 3 of the Business and • LIC A'.0 9 5.1 A
Professions Code, and my license-is in full force and effect CITY. CLASS A 0 0., 0 0
- 'SQ FT too
'OF NO',OF',: '. CHECK" , # o'0 0 0 0 .1
License Number TR t;'11113 Lic:Class` �O SIZE RIES FAMILIES ONE ri
Contractor T�7 1• _ Rob f i nQ Date 10.1'6 8 4, . DESCRIPTION OF.WORK '�W ,2 8 5 0 v
❑ o.o o =
❑ ADD -
am exempt under Sec. ALTER ❑ FINAL 0.'2W-!-'8 4
B.&P.C. for this reason i. of^, ® L/
_ •��'•�.„', - - DATE -
' REPAIR
USE OF FIN
t EXISTING-BLDG ReS1ClenCe: DEM6L ❑ B
Signature APPLICANT. TEL
`OW ER-BUIL DE TIO PRINT +,;, a. NO 2— 171
I hereby affirm that lam e� mpt from the Contractor"s License Q '
Law for The following re son (Section 7031'.5, Business and ADDRESS 4"8 - E. walnd, PaSa. 91107 - T -
Professions°Code): ""
❑ "• -', BUILDING”;4 9 0 8Hal lowe 11.,. .
I,,as owner of.the property, or,my,employees with ADDRESS ,
.wages as`their'sole compensation,-will do,the work and
th'e,structure.is not intended or offered for sale(Section - LOCALITY
7044, Business and Professions Code). MOVING TEL
CONTRACTOR '�--.; NO.
❑• I, as„owner of the*property, am exclusively,'contracting•• _
with licensed•contractors•to-construct-The project (Sec-
tion 7044, Business and Professions Code). rADDRESS'
,CONSTRUCTION UIRED” -SETBACK FROM EXIST.
BACK YARD ,�HWY pROP•LIN WIDTH
I hereby affirm that there is a construction lending'agency for _, NT u.
the performance'of work for,wh'ich.this-permit,is issued �1
(Sec. 3097, Civ. G ). ', ; .
o `Lender's•Name - - .� eermft'Fee' ,'18 00Lender's Address`I ce-rtify that'1.have-read"thisapplication and state that the Issuance Fee~above information is correct.'I`agree to comply with all County gation Fee
g 'ordinances and State laws relating to�building-construction, Total Fee ,
t and hereby authorize representatives of'this,County to enter
up the bove-mention property-for ins ection.purposes.
�d SEE REVERSE FOR EXPLANATORY LANGUAGE t
SignaturePlicant or Agent Da