HomeMy Public PortalAbout9941 HOWLAND DR_Building__ WORKERS'COMPENSATION DECLARATION :
hereby affirm that.*l have+a certificate.Cif consent to self o M d D G 1' ', p C 1 0 U
' insure, or a certificate of Workers' Compensatjon Insurance,
or a certified copy thereof'(Sec.•3800; tab: C.)' COUNTY OF LOS-ANGELES
NGELES BUILDING AND SAFETY
Policy No. Company
BUILDING `
Certified copy is:hereby furnished, FOR APPLICANT,TO FILL IN ADDRESS
La,14 t2
Certified copy is filed'with the county building inspec- BUILDING
Tion department. - ADDRESS LOCALITY
--,r .� ! �1 NEAREST
Date 1 Applicant CITY ZIP L 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 irfor one // �/�/ / / USE ZONE MAP
hundred dollars ($100)or-less.) TRACT 1i J-? BLOCK LOT NO. /' / NO:
TEL``// ll �- �. SPECIAL
I,certify that in the performance of the work for which this OWNER 'Tl �L� NO`lL1, CONDITIONS
permit is issued, I shall not employ any person in any manner II / DISTRICT GROUP TYPE FIRE PRO ESSED BY O
so.as to become subject to the Workers'. ompens tion aws. ADDRESS 1 (�1 CONST. ZONE
Date 1 Applicant �'Y Vt CITY ZIP L STATISTICAL CLASSIFICATION
APT. JCONDO. O
ARCHITECT OR TEL.
NOTICE.TO. APPLICANT: If,:after-'making this Certificate of V
ENGINEER NO.
Exemption, you -should become subject to the Workers' CLASS NO_12�/_DWELL. UNITS I&A
Compensation provisions of'the.Labor Code, you must,forth'- H
with comply with such provisions or this permit shall 6e ADDRESS SEWER MAP ,/ z
deemed revoked. TEL.. BK. PG,�3 VALIDATIONCONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION . LIC.
I hereby,affirm that I am licensed under provisions'of Chapter 9 ADDRESS - NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and.my license is,n full force and effect. CITY CLASS' $ d
SQ. FT. NO. OF / NO. OF ) CHECK
License Nu ber Lic:.Class SIZE STORIES l FAMILIES. ( ONE
DESCRIPTION OF WORK NEWEl $
Contract'
J Date
s ADD
O 1 am exempt under Seca •: O
ALTER FINAL
B.&P.C. for this reason REPAIR DATE
Date: - USE OF FINAL r
EXISTING BLDG: DEMOL ❑
APPLICANT ,q p f` TEL. . C' BY
Signature. PRINT -Plf �•'1 NO.4 T47a ~'
OWNER-BUILDER DECLARATION D 0045 5A
I hereby affirm that I am.ezempt from the Contiactor's License
Law for.the following reason (Section 7031.5, Business and. ADDRESS + `
Professions Code): PRESENT o 0 0 0 0.1
Q BUILDING
F1-
as owner of the property, or my employees with ADDRESS' c 0 7 0 0
wages asaheir'sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY a`o o"7$ 10 0 '
'7044, Business and Professions Code): MOVING TEL.
❑_- I, as owner of the property, am exclusively•contracting CONTRACTOR NO. 03. 1 5—8 3
with licensed-contractors to construct the project:(Sec-.
ADDRESS
V!/
• tion'7044;Business and.Professions Code). �
REQUIRED TOTAL SETBACICFROM EXIST.
CONSTRUCTION-LENDING AGENCY: SET BACK YARD HWY PROP. LINE WIDTH
hereby affirm that there is a'construction,lend ing'agency,far.- FRONT
the performance of the work for which this'permit is issued . P.L'
(Sec. 3097; Civ. C.).:" SIDE. s r
FO P.L. w L;
Q
Lender's Name - '^'
r '4
Lender's Address P.C. Fee$' Permit Fee- 7 J
I certify that I have read this application and state that the Issuance Fee U
above information is correct. I agree to comply with,all County Investigation Fee
8 ordinances and State laws.relating to.•building construction, Total Fee
d and hereby authorize'representatives 6f'this County to enter
m upon the abo men. ed property for inspection purposes,
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent 'Date - - ..es