HomeMy Public PortalAbout9811 HOWLAND DR_Building__ —r7 4- -5/- F
WORKERS' COMPENSATION DECLARATION 7
I hereby affirm' hat homecertificate of consent to self APPLICATION FOR BUILDING PERMIT
ir�ure,» ar hiTicate of Worr kers'Compensation Insurance, •
`or 6'certifiedcopy thereof ( ec. 3800(IV �ytalJ},,C.I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No?St) 3 4. ponyV{4Ic FNM� BUILDINU
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN ADDRESS // 2
Certified copy is filed with the county building inspec- BUILDING-a9sxlu ) J
tion deppartmOent. ADDRESS 1 ow 1 o t7 LOCALITY
Date )0-7—q6Appliconl NEAREST
CITY^ ZIP CROSS ST.
CERTIFICATE OF EXEMPT104 FROM WORKERS' p NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT r 2..3 O NOW ON LOT I MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ZONE MAP Y/ q
hundred dollars ($100)or less.) TRACT I Z�+JV BLOCK r LOT NO. 7 NO.
C TEL -/ SPECIAL
- y
I certify that in the performance of the work for which this OWNERGVY111 W( C NO. CONDITIONS d
permit is issued, I shall not employ any person in any manner �E p ( CONST,,C7 DISTRICT G P TYPE FIR
ADDRESS w IQ G1 E OC ED BV_NE U O
1 C O
so as to become subject to the Workers'Compensation Laws. B� J ' D /J �2 `- - �.
CITY '1QH'L /C CtT ZIP 6 J O
Date Applicant STATISTICAL CLASSIFICATION APT. CONDO, F-
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.
Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS_ d
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N
with comply with such provisions or this permit shall be Z
deemed revoked. TEL' BK. PG. ,� VALIDATION
CONTRACTOR rt Ll lid r NO. 33
LICENSED CONTRACTORS DECLARATION �/ LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1 0p 07 . 41, a N0.3 �a0 VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY 1° V L Y7 CLASS $
3787 f O SO. F . c NO.OF NO.OF CHECK
License Number 10n Lic.ClasS�v_ SIZE J STORIEpS 1t FAMILIES ONE L
9 U e� Dote 10-ZN-O Fa DESCRIPTION OF WORK rJ�1 NEW ❑ S
Contractor >,2gtros us
ADD
I am exempt under Sec. O kA4!fie U
ALTER ❑ FINAL
B.BP.C. for this reasonREPAIR ❑ DATEnrr M
USE OF /
Date: EXISTING BLDG. DEMOL ❑ FINALS
Signature
APPLICANT TEL. BT I_
OWNER-BUILDER DECLARATION PRINT D NO. 3 jjyy++yy�/1�1i1' � -
I hereby affirm that I am exempt from the Contractor's License ► l�r-�• bVJr'�i!✓/
Law for the following reason (Section 7031.5, Business and ADDRESS le UI N
Professions Code): FKtbtNI
O -
I, as owner of the property, or my employees with BUILDING
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY \ t ` ` •,� .
7044, Business and Professions Code). MOVING TEL. � r j
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- 1
tion 7044, Business and Professions Code). ADDRESS �9 5 8 6 6 A
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LIN WIDTH e e e.e
REQUIRED TOTAL SETBACK FROM EXIST. ,I
# s
I hereby affirm that there is a construction lending agency for FRONT pool performance of the work for which this permit is issued P.L. ( o o 7 a 0 0
(Sec. 3097, Civ. C.). SIDE
P.1. e e e 7 8 0 Q.FJJ '
1\
Lender's Name
s 5—a YL0586
Lender's Address P.C. Fee$ Permit Fee '
certify that I have read this application and state that the Issuance Fee y
above information is correct. I agree to comply with.all County InvaStigalion Fea
g ordinances and State lows relating to building construction, _ To,.]Fee
G and hereby authorize representatives of this County to enter
upon the pbove- an 'on d operty for inspection purposes.
`.0-2,01 UeSEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Data ®s