HomeMy Public PortalAbout9823 HOWLAND DR_Building__ r% -+ WORKERS' COMPENSATION DECLARATION - -
;, hsure,' 6 cer that 1 have r certificate of consent to self APPLICATION -FM BUILDING PERMIT
thsure, or certificate of Workers' Compensation Insurance,
.�wa certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY -
Policy No. Company -/�
copy y BUILDING Cf��
❑ Certified co is ereb furnished. pp FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy Is filed with the county building inspec- ADDRESSUILDING U v� ��(-dE•�p
tion department.
CITY TL1- L-U, G r o ZIP l 17 00 LOCALITY
Date Applicant / NO. OF BLDGS. / NEAREST '
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT( Zr'J Z. NOW ON LOT CROSS ST.
COMPENSATION INSURANCE - - ASSESSOR p y�
(This section need not be completed If the permit is for one TRACT BLOCK LOT NO. (81$ MAP BOOK 0�/ PAGE /7'5' JARCEI406
hundred dollars ($100) or less.) TEL
OWNER N USE ZONE MAP
G
I certify that in the performance of the work for which this NO.
Q'�}p SPECIAL >
permit is issued, I shall not employ any person in any manner ADDRESS ( Z� H OLL�L_kL,f C) 1Z —/ CONDITIONS d
so as to become subject to the Workers'Compensation Lows. /- 0
CITY—Fa-5-00L{ua l—) zIP l ��G
Date Applicant ARCHITECT' TEL. DISTRICT GROUP- TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER -4COE 1.L N0.2�O-0`'JtJ CONS1T./ NE
Exemption, you should become subject to the Workers' ADDRESS x522 Jt G� � � �QQ •� Y [ a
Compensation provisions of the Labor Code; you must torch-
-
with comply. with such provisions or this permit shall be " TEL STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR - 5
LICENSED CONTRACTORS DECLARATION UC CLASS NO. �� DWELL UNITS
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 361'��^�� NO. SEWER MAP --
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and my license is in full force and effect. CITY — CLASS BK PG MiVAUa'ATION
ClSQ. FT qp NO. NO. OF CHECK - -- _
License Number. Lic. ass SIZE Cj STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK 1�'ZL?ZI RJ NEW
Contractor Date ADD $ "=2� 2�3 --
ElI am exempt under Sec. ALTER ❑
B.BP.C. for this reason $
_ _ ,� a REPAIR ❑
Date: USE OF (•I �. AwT' DEMOt ❑ "�,yt•!.0- .LI.1 .
EXISTING BLDG,
r�r' s
SignatureAPPLICANTK r TEL 0�6 FINAL
OWNER-BUILDER DECLARATION (PRINT) N NO. DATE
I hereby affirm that I am exempt from the Contractors License '• RESS 5Z 2.
Law for the following.reason (Section 7031.5, Business and ADDSt AiWiaL.a MOmTi �� FINAL
Professions Code):_ - PRESENT BY
❑ I, as owner of the property, or my employees with BUILDING U JL
ADDRESS g
wages as their sole compensation,will do the work and
the structure is not intendedoroffered for sale(Section LOCALITY
7044, Business and Professions Code.) MOVING - TEL
1, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS i!,(at till
tion 7044, Business and Professions Code.) _ r
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 7'
r.
I hereby affirm that there is a construction lending agency for FRONT • '1• �.f +5 i;„11j_
the performance of the work for which this permit is issued P.L.'
(Sec. 3097, Civ. C.). SIDE
Lender's Name g LDMA R.I. �.f'A- t'r'F-U 1 -
ij
I P.C. Fee$ of / al, Permit Fee �77� 17-
Lender's ,
Address �,
I certify that I 8 have read this application and state that the Issuance Fee LDMA P/C#above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee (/ /• / LDMA Perm. #
a and hereby authorize representat'ves of this County to enter
upon the o e-menti operty for inspection purposes. -
7
SEE REVERSE FOR EXPLANATORY LANGUAGE
5 gnry re of Applicant or t Date