HomeMy Public PortalAbout5646 HALLOWELL AVE_Building__ WORKERS' COMPENSATION DECLARATION
I herebyaffirm that'l have certificate of consent to self
insure, orr a certificate of Workers' Compensation Insurance,
or+a certified crspy'theredf (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES B ILDI SA E, Y
Policy No; __ _Company SZXLZ1< 9-Ir Al2)
BUILDING
Certified copy is hereby furnished. .. FOR APPLICANT TO FILL IN',,,- ADDRESS EA LLQ LL
:Certified copy is filed With county wilding inspec- BUILDING
Tion department. ADDRES L V b -rG eA I O D
r2 CITY "TEM L� T ZIP C DO'& LOCALITY
Date''.Applicant C
i NO. OF BLDGS. NEAREST
C RE TIFICATE OF EXEM ZQAA AAAQRS'. -"--- SIZE OF LOT So 1C Sa I NOW ON LOT CROSS ST.
- COMPENSATION-INSURANCE ASSESSOR // /�
(This section need-not be,completed if The permit is for one TRACT MAP BOOK (O PAGE PARCEL
hundred dollam($100) or less:) TEL. �! Q u5 ONE MAP
-OWNER ' i'J NO. 7743�J NO. �d X73
I certify that in.the performance of,the:work for which this r` SPECIAL, }
permit is issued, Lshall-not employ.anyperson in any manne ADDRESS_ / CONDITIONS n
so.as to become subject to the Workers'.Compensation Law . 011,
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CITY S ZC t P �WJ
Date Applicant ARCHITECT OR TEL. W
�- DISTRICT,. ;GROUP TYPE•. - FIRE PROCESSED BY
NOTICE TO APPLICANT: if, after makingthis 'of. ENGINE#R - L.NO.0 [8�tkol-'2�W
\ CONST. ONE H
Exemption, you should. become-subject to the Workers' U
Compensation provisions of the Labor Code, you.must forth- ADDRESS v ..3 ✓ Gls� e+�E� LU
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. _
LICENSED CONTRACTORS DECLARATION LIC." CLASS No. G_bWELL. UNITS f/
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
't .. 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. CITY ' CLASS BK PG. oVALIDATION
SQ. F OF '
NO. OF r CHECK
License'Number �C /� 7JT J Lic: Class SIZE STORIES WFAMILIES 01V ONE 4
® VALUATION
- Contractor9`� �n3� Date DESCR TION WORK NEW
ADD .❑ __•
❑1 am exempt under Sec
ALTER ❑_ �CO� OOO oa t _. ._..
B.BP.C:for this anon $ _
RE AIR'
6 USE OF a
Date i '
q EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL FINAL a
- -- - (PRINT). NO.
OWN -
DATEIt-
Low '
i
I hereby affirm that'Lam exempt from the Contractor's License _ -
for the following reason (Section;703T 5 Business and il ADDRESS �i
Prof ions Code) , PRESENT BY FINAL
BUILDING G
I, as owner of the property, or my--employees with ADDRESS �3 0 r v t
Wages cis their sole compensation;will dothe work'and OCALITY
_ fl'
• the structure is not intended or offered for sale L
(Section 7" •• -- ,_h_
7044;-Business and Professions Code.) MOVING TEL.
CONTRACTOR NO. Z
.el, as owner of The property, am exclusively.contracting Z 0 -�
with'licensed contractors to construct 4he project (Sec- ADDRESS ��� v i '- -+ ; `
tion 7044, Business and Professions'.Code.),
REQUIRED TOTAL SETBACK FROM EXIST. /
CONSTRUCTION LENDING'AGENCY-' SET BACK YARD HWY PROP. LINE WIDTH - , i=•t'w
I hereby affirm that there is a coristruction.lending agency for. FRONT Z I t L' 1
the performance of the:work for which this permit is.issued P.L. 2
(Sec. 3097; Civ'. C,):. SIDE, t
P.L. ..
Lender's Name �1 x�+
Lender's Address P:C. Fe 63 63• * Permit Fee �V o 9/ LDMA Ref. # 1J.
`�//i�
o 16
I certify that I have read this application and state that the /✓ Iswance Fee / LDMA P/C#
0
above information is correct. I agree to comply with all County Investigation Fee
'8 ordinances and State laws reloting to building construction, Total iFe D I LDMA Perm. #
a and hereby authorize representatives of this County to enter
upon the ove-mentioned property for'inspection urposes.
, ll 3 161 -SEE REVERSE FOR EXPLANATORY LANGUAGE
Si na re of Applicant or Agent' Dat