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HomeMy Public PortalAbout8644 HERMOSA DR_Building__ WORKERS' COMPENSATION DECLARATION 81-1013 Woods hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers's'CoCompepensfion Insurance, or a certified copy thereof (Sec 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY _ �cyal-45882 CompanyFremont Indemnity BUILDING Certified copy is hereby furnished. FOR-APPLICANT TO FILL IN ADDRESS S�—I Certified copy is filed with the co uniy building inspec- BUILDING )L1 tion department. ADDRESS 8644 Hermosa Dr. LOCALITY Date 8/5/81 Applicant Rigid Mfg- Company NEAREST _ CITY n briel ZIP - CROSS ST. • CERTIFICATE OF EXEMPTION FROM WORKERS" NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars ($700)or less.) TRACT BLOCK LOT NO. NO, Y TEL. / SPECIA Q I certify that in the performance of the work for which this OWNER NO. CONDITIONS O o -DISTRICT GROUP TYPE FIRE PRO SSED BY" V permit is issued, I shall not employ any person in any manner ADDRESS 8644 Hermosa Dr. CONST. ZONE so as to,become subject to the Workers'Compensation Laws. �/3 r/ OC Date Applicant - CITY ZIP STATISTICAL CLASSIFICATION Y PT. CONDO. O . ARCHITECT OR TEL. "NOTICE 70 APPLICANT: If, after making this Certificate of ENGINEER NO, CLASS NO. � DWELL. UNITS_ d W Exemption, you should become subject to the Workers' y Compensation provisions of the Labor Code, you mast forth- ADDRESS SEWER MAP Z with comply with such provisions or this permit shall be �i/- deemed revoked. i id Mfg. Coma NoL26 - 81 C Y7 VALIDATION CONTRACTOR BK. �'PG, LICENSED CONTRACTORS DECLARATION _ LIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS S.-Woods Ave NolS �' 6 VALLI ON (commencing with Section 7000)of Division 3 of the Business and - LIC. $ Professions Code, and my license is in full force and effect. - CITY S. eles C8 0022 CLASS C-39 50. FT. NO. OF NO. OF CHECK License.Number. 159496 Llc.Class C-N SSTORIES FAMILIES ONE ' 8/5/81 a Contra<toh2i gi(1 �g. COmaIIVhateDESCRIPTION OF WORK geo f with id "Et^' d - I am exempt from the licensing requirements as I am prepared Class "Ctt material ADD LJ I licensed architect or a registered professional engineer _ ALTER 1��1--1!!1 FINAL �J /J /� r -acting in my professional capacity (Section 7051, t`pp DATE / , c{ Business and Professions Code). USE OF REPAIR DEMOL FINA� EXISTING BLDG. ❑ By , Lic:or Reg. No. Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) - NO. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS I Professions Code): I - PRESENT — ❑ - I, as owner of the property, or my employees with BUILDINGADDRESS wages as their sole compensation,will do the work and ' the structure is not intended or offered for sale(Section LOCALITY - 7044,-Business and Professions Code). MOVING TEL. - x,8;7 2.7 A I, as owner of the property, am exclusively contracting CONTRACTOR NO. - # with licensedcontractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code): CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. I ° ° 2 1,.,5 Q SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT 'e a e,Z 5 Q v' the performance of the work for which this permit is issued P.L. - (Sec. 3097, Civ. C. ' SIDE PL 8 1 2.—.81 Lender's Name _ qq Lender's Ad rens ` P.C. Fee S Permil Fee 1 certify of have read this p cation and state that the Issuance Fee above ormafion is C.rrcct..l gre to comply with all County Investigation Fee ordi a es and Statjlo�s, lagie building construction, iolal Feea h reby oulhoaznof this County to enter a Pon the abovor inspection purposes. , `a - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature AP. icant o Agent Date ©s