HomeMy Public PortalAbout9948 HOWLAND DR_Building__ WORKERS' COMPENSATION DECLARATION
-;cffcertificate consentInsurance, �RJD� V E RM I Tinsure, dracertifcate of Workes' Compensaton APPLICATION F
qr a certifPed copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BU ING f&D SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. . FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING �,/�!!
tion department. ADDRESS
Date Applicant CITY ��H+ / �1 ZIP y/7 LOCALITY
NO. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT�'� /��f,S' NOW ON LOT �' CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK -00 PAGE ��.� PARCEL t049
hundred dollars ($100) or.less.) TEL. �7 USE ZONE
OWNER C DII� Co NOJSk MAP j /�r� NO. 1'517 h'd2
certify that in the performance of the work for which this 1 y
SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS � / Vu�it�4 CONDITIONS a
so as to become subject to the Workers'Compensation-Laws. �J �+ O
CITY TLI� j[ Gf s, ZIP /t<�S°� U
Date Applicant ARCHITECT OR TEL. 0
NOTIC TO PPLI ANT: If, after making !,Us Certificate of � ENGINEER p�jn �*C� NO.gqSZ•h Q� DISTRICT GROUP CONST. ZONE PROCESSED BY O
Exemption, you' should become subject, to The. Workers' n U
Compensation provisions of the Labor Code, you must forth- ADDRESS %Z lj Dv�L.�i - cl -LA �� rr4'i1 �0 d
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR -AkWZe- NO. �'�2� Z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. OI DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 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 �� VALIDATION
SQ. FT. NO. OFNO. OF CHECK
License Number Lic. Class SIZE �jl� STORIES 1 / FAMILIES i ONE Q 7
VALUATION
Contractor Date DESCRIPTION OF WORK NEW -` �5�14
ADO ryr�
❑1 am exempt under Sec. ,� ❑ , �"� 7 7d
�1 ALTER ❑ �'
d d C)
B.&P.C. for this reason �\JO
USE OF REPAIR ❑ ;
Date: 10 EXISTING BLDG. � DEMOL ��•�000�
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION \ (PRINT) NO. DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5,'Business and ADDRESS FINAL
Professions Code): PRESENT By
,i BUILDING !+.'_•; z
❑ I, as owner of the property, or my employees with ADDRESS p _
wages as their sole compensation,will do the work and /`�'the structure is not intended or offered for saleSection LOCALITY - •-_-
7044, Business and Professions Code.) ( MOVING TEL. , =T __
I, as owner of The property, am exclusively contracting CONTRACTOR NO. 6 7 - -
� ��
with licensed contractors to construct the project.(Sec-
ADDRESS
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST. CH�t_.}'; •`r
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 7f;`(
I hereby affirm that there is a construction lending agency for FRONT {:1}•:4f Ill i
the performance of the work for which this permit is issued P.I.
(Sec. 3097, Civ. C.). SIDE .
P.L.
Lender's Name /�lJi7N� '
_? ^ LDMA Ref. # - - '' -
P.C. Fee$ (J. / Permit Fee �f i a-CJ aF g 7 _ � . .,.;
Lender's Address / ,�/
o I certify that I have read this application and state that the �U�G+. 0o Issuance Fee a 7✓ LDMA P/C# ,
8 above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total FewV1f- / LDMA Perm. #
a and hereby authorize representatives-16f this County to enter
upon The above-mentioned.propep or inspection purposes.
_Q
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant Agent Date j