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HomeMy Public PortalAbout6008 IVAR AVE_Building__ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a.certificate of Workers' Compensation Insurance, or a'certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby,furnished.. : FOR'APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING 1� �' tion deportment.' ADDRESS �© _J Date Applicant CITY ' ZIP LOCALITY J CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT O. OF BLDGS. NEAREST NOW ON LOT CROSS ST. COMPENSATION INSURANCE (This section need not be completed if:the'permit.is for oneASSESSOR' hundred dollars ($100)or less.) TRACTBLOCK LOT NO. MAP'BOOK PAGE PARCEL , TEL USE ZONE MAP OWNER I certify that'in the performance of the work for which this n� NO. permit is issued, I shall not employ any person in any manner El � J� SPECIAL so as to become subject to the Workers'Compens�ra—W—S ADDRESS CONDITIONS / cv n Q `Date• � Applicant - CITY �Q ZIP - � NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROC SED BY O Exemption,. you should become subject to' the Workers' ENGINEER NO. CONST. ZONE U Compensation provisions of the Labor Code, you must forth- ADORES � 7 LU with comply with such provisions or this permit shall be p -D. deemed revoked. CONTRACTOR �L` �©� STATISTICAL CLASSIFICATION APT. CONDO. (A LICENSED CONTRACTORS DECLARATION r LIC, CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS/5 (commencing with Section 7000)of Division 3 of the Business and p LIC. SEWER MAP Professions Code, and''my license is in full force and effect. CITY 1 "1� CLASS BK PG VALIDATION �Q n o� C� SQ. FT. NO.OF NO.OF CHECK License NumbdLic.Class(2L ` SIZE STORIES FAMILIES ( ONE VALUATION Contractor C �� Date✓ 3y DESCRIPTION OF WORK ce C_6� NEW $ { f) ADD ❑ D I am exempt under Sec. w P ` ❑ ALTER B.BP.C. for this reason ) REPAIR $ Date: USE OF DEMOL ❑ 2.9 5.1,3 A EXISTING BLDG. Signature APPLICANT TEL.' .# o ®,o.o 0,1 OWNER-BUILDER DECLARATION PRINTFINAL DATE hereby affirm that I am exempt from the Contractor's License o 6.4,0.5 0 Law for the following reason (Section 7031.5, Business and I ADDRESS B O O O j/ 4 Q 5 0 U= Professions Code):... _ • - PRESENT . . ❑ BUILDING I, as owner of the property, or my employees with ADDRESS e 0 J.0'J`.8 8 wages as their sole'compensation,will d64he work and D the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project(Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM –EXTST-1 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT ° the performance of the work for which this permit is issued P.L. (Sec..3097, Civ. C.'). SIDE Lender's Name /p LDMA Ref. M' . Lender's Address P.C:Fee$ Permit Fee G J I certify that I have read this application and state that the Issuance Fee < LDMA P/C# D above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, g Total Fee. 6 and hereby authorize representatives of this County to enter LDMA Perm.,# mon the ab ve-mentioned r y r inspection purposes. c=C � F t� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date