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HomeMy Public PortalAbout6012 IVAR AVE_Building__ '-.rVORKEIZS' COMPENSATION DECLARATION l" hereby affirm&hat-14aye a certificate,of consent to self p SWUM D O. h tsure, ora certificate of Workers'Compenstion Insurance, or ' Q p d Lr-\x Q D d D D ]Cep p C G3� certified copy thereof.(Sec. 3800,'Lab. C.) COUNTY,OF LOS ANGELES BUILDING AND SAFETY olicy No. Company _ Certified copy is hereby furnished. FOR APPLICANT TO FILL' IN ADDREss Certified,copy is filed with the-county building i.n\pec- BUILDING1 }ion department: ADDRESS 6,01A '� t`'/ LOCALITY' NEAREST ate .Applicant•- CITY -e, 01 ••- ZIP 9/ CROSS ST. '•CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT 'r/' O NOW ON LOT MAP BOOK PAGE PARCEL MA Phis section need not be completed. if the permit is for one Y7 �� USE ZONE NOP Lr undyed dollars ($100)or.less.). TRACT BLOCK LOT NO. / 1! /O�n SPECIAL certify that in ihe.performance of the work for which this OWNER Ir/f� Oh LJQ' v NO CONDITIONS CONDITIONS / -0 ermit is,,issuecJ, l shall not employ any person m any manner DISTRICT GROUP TYPE' FIRE PR ESSfiBiBY r - ADDRESS6101 J21I/.f� - 4� \_ �'� .-� CONST. ZONE o as to become subject to the Workers'Compensation Laws. _ / 1 / O ate/rr%C ��j A' lican ' z ' CITY CI71 (�� ZIP STATC�ALCLASSIFICJATION !� PT. COND0.v PP ARCHITECT O ^ ` TEL /� IOTICE TO ,APPLICANT:, If; aft r making this'.Certificate of ENGINEER (,"fly N056�7� CLASS NO. a.L_DWELL. UNITS xemption you' should becorne subject 'to the Workers' ompensation provisions of the Labor Code,..you'must forth- ADDRESS_:>;XpJ^ • SEWER MAP TEL iith comply with-such provisions or;this permit shall be !� . / ' ` eemed revoked. ,;. CONTRACTORS.)� "� NO' BK. PG, VALIDATION " LICENSED CONTRACTORS DECLARATION' " LIG hereby affirm that I am_licensed under provisions of Chapter 9 ADDRESS NO. _ .VALUATION :ommencing with'Section 7000) of Division 3 of the Business and LIC. rofession.'s.Code, and my license.is`in full force and'effect. * CITY CLASS $ SQ. FT. NO. OFNO. OF CHECK' icense Number Lic.Class SIZE ORISTORIES FAMILIES ONE_a $ / ;DESCRIPTION OF WORK. NEW• - o'ntractor Date ADD 1. 6 6 A I am exempt from the licensing requirements as I am a LS j licensed architect o a registered professional engineer•' ALTER 0 FINAL acting in' my professional capacity (Section 705.1, u� h n 4A REPAIR ' DATE '�'"' `� n # °. ° ° ° 2•v R Business and'Professions Code), USE OF - EXISTING BLDG. DEMOL FINAL 2 0 1 8�,(j {J ic:or Reg No Date APPLICANT �/ TEL: p/ /� (PRINT) 16,6A9 j".tJB/Qnb'P oNoL 4J G' /6-&7 0 0 4 OWNER'BUILDER"DECLARATION n� ?� hereby affirm that I am exempt from the Contractor's License ` ' a Ii ) i/�� -icy / 5 aw for the following reason (Section 7031.5; Business and ADDRESS J� JV • v 7 c� l 0,�1 8 1 'rofessions Code). PRESENT r BUILDING I, as owner of the property', or my employees with ADDRESS' �'-�C/ �0 wages as their sole compensation,wili'do'the work and ( ' LOCALITY the structure"Is got'intended or.'offered for sale'(Section (/ ' I 5 6,7'A. 7044,'Business and Professions`Code). MOVING TEL. I, o"owner of theproperty,. am exclusive) contracting CONTRACTOR NO. Y 9 .0:0•'0 0 0 1 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED YARD HWY TOTAL SETBACK - 2,a 3 2&5 0 CONSTRUCTION LENDING AGENCY SET BACK PROP.'LINE WIDTH WIDTH hereby affirm that-there is.a construction lending agency for FRONT Q ® 2 o 6-D 2 3 5(� , he performance,of the work for which'this permit is issued P.L_ > - _ So Sec. 3097,.Civ. C.)., SIDE '.@ 1 5.7-8 1 ender's'Name' / p- ender's Address P.C. Fee$ /. Permit Fee / (p v f? r certify that I have read this application and state that the /�/ 4Ca , Issuance Fee' / above information.is correct. I agree to comply with all County Investigation Fee ,rdinances and State laws relating to building construction, Total Fee ! f� ind hereby authorize representatives of this County to enter Pon the above-mentioned property for inspection,purposes. Ar �! SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Signature o Applicant or Agent - - Date