HomeMy Public PortalAbout6031 IVAR AVE_Building__ WORKERS COMIZENSATION DECLARATION
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I herebyaffirm . t U have a certificate of consent, to self D D D OO D
insure, or a'certifica a.of W.orkers',Compensation Insurance, la p p d 0 CQ ;�TOM . 00 LBOHS",p �G�r
or a certified.copy.thereof (Seca 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 J
e
Crtified copy is filed with the county building-inspec BUILDING /
a '.tion department. ADDRESS . 6 03/
,Dote Applicant CITY, / zF.A1t .C,C C,qY ZIP LOCALITY.. �
CERTIFICATE.OF EXEMPTION,FROM WORKERS SIZE OF•LO NO.O F B DGS NEAREST
'� .- L ARES
COMPENSATION INSURANCE
T NOW ON LOT CROSS ST.
(This section need not be completed if.the permit is for.one TRACT BLOCK - LOT NO. LO MAP BOOK, PAGE PARCEL
�j�/' !
hundred dollars,($100)or less.) - r v _
TEL.
I certify that in the.performance of.the work for which this OWNER e ,,// NO. USE Z NE MAP
periinit is issued, I shall not employ any person in any manner ADDRESS V SPECIAL
✓/'� CONDITIONS
so as to become subject to the Wo ers Compensation Laws.. U
L�� /. 7 t CITY %�//u�f.�i L' ZIP
Date Applicant � `�!y/ '✓"� ,.
ARCHITECT OR TEL'. DISTRICT TYPE FIRE NOTICE TO APPLICANT:•°If,.after makmg.'tliis;Certificate of ENGINEER NO. ICT GROUP R PROCESSED BY O
Exemption, you`should become subject' to.'.,the Workers' ry ,( CONSL". Z NE
Compensation provisions of the Labor Code, you•must-forth ADDRESS <lt v U
LAI.,y
such provisions or-this peimit, shall be 'TEL.:���
STATISTICAL CLASSIFICATION . APT., CA
deemedwith,-.comply'.
,revokedLICENSED CONTRACTOR.Y,40�D "'0 9,S NO. 7 �:$G°' '
! CONDO.
p
CONTRACTORS DECLARATION - LIC. CLASS NO DWELL. UNITS
C.
I herebydffirm that tam licensed under provisionsof.Chapter9 ADDRESS 3 f5L?PCC:Y.Ls/ NO.
(commencing With'Section'7000)of DrvisionJ.of the Business and LjC SEWER MAP
Professions Code, and my license is irfull forcdlcnd effect:' CITY fW-5 4 CLASS eK. 1 �:• VALIDATION
SQ.FT. NO. OF NO:OF CHECK. ,
Number'" , � Lic'Class '�' / SIZE •' STORIES FAMILIES ONE `
.,License-Numb ,
r> 7 V1AATION
Contractor Ut� GIOSS Date// r'7� DESCRIPTION OF WORK NEW..
'Q
rtL� C FS-civF� _RE:B�L. A
a I am exempt under Sec DD
, ALTER �
• -B.BP C. for this reason � •' REPAIR '
USE OF `
'Dote EXISTING BLDG. DEMOL .
Signature APPLICANT TEL III FINAL
PRINT .D/?'v14) �-)Q$s N0..7�r6 6�0� - 8 3 7 7 A
OWNER BUILDER DECLARATION Dd1TEh; h
I-hereby offirm that]lam exempt from the•Contractor s License
i
ADDRESS.02 23:• DcFf�L�y ST >�✓�/l�' C'
Professions Code' (Section 7031 5 Business and 41.
BSN
Low folr tas ownerofthesprop
g
BUILDING. o o '�
arty, or my employees with ADDRESS T
Y '
wages ds'their sole compensation,will do the work and o 0 2875_06
the structure is.not intended or offered for sale(Section LOCALITY
7044, Business and,Professions Code). MOVING TEL-
71
EL. '
CONTRACTOR NO.. I 'i 7._.p 8,7` .
aI,as owner of the property, am exclusively contracting 9
with-licensed contractors to construct the project (Sec-
ADDRESS
"d Professions*
tion 7044, Business.a N'LENDING AGENCY SET BACK YARD 'HWY• PROP. LINE. WIDTH. ,
).
CONSTRUCTION REQUIRED, TOTAL SETBACK PROM
6 hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L:
(Seca 3097, Civ. C.).' , SIDE.,
Lender's Name .
P.L.
P.C, Fee$ Permit Fee tJ 1
" LDMA Ref: #
Lender's Address ,
o I.certify..that I have read this application and state that the Issuance Fee V s LDMA P/C#
above information is correct.1 agree to comply with all County, Investigation Fee.
0 ordinances and Stole laws relating to building construction, Total Fee LDMA Perm.-#
and hereby authorize representatives of this County'to enter
• up the above-mentioned property for inspection purposes.
��-az /^y7 SEE REVERSE FOR EXPLANATORY LANGUAGE .
Signature•of Applicant or Agent Date ,