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HomeMy Public PortalAbout9033 JAYLEE DR_Building_3/20/1989_reroof WORKERS' COMPENSATION DECLARATION P hereby affirm that I have a certificate of consent to.self 0 O D n O O M O D nn insure, or a certificate of Workers' Compensation Insurance, A P P��CL UPON FOR FO) or a certified copy thereof (Sec; 3800, Lob. C`): COUNTY OF LOS ANGELES' 'BUILDING AND"SAFETY Policy No Company ! r El Certified copy is hereby furnished. FOR APPLICANT TO-FILL'IN BUILDINGADDRESS- ❑ • Certified copy is filed with the county building inspec- BUILDING O ✓ f, - h ADDRESS ✓ tion department. l _Cib(1J1f1 IP ZIP Date Applicant CITY /�� LOCALITY B NO. OF LDGS. NEAREST CERTIFICATE OF'EXEMPTION FROM WORKERS' SIZCOF LOT NOW ON LOT CROSS ST. COMPENSATION.INSURANCE ASSESSOR (This section need not be,completed if the permit is for one TRACT` BLOCK LOT NO. G MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) 8` OWNER 'iT6 , c_ n -NO. US ONE., NO., 5 v� I certify that in the performance of the work for which this q SPECIAL: >- permit•,is issued; I shall not employ any person.in any.manner - ADDRESS, (� V LQ 1 a. CONDITIONS so as to become-subject to the Workers' ampensation Laws. 1 pp 0 . CITY ZIP: . 2 !� Date App an � ARCHITECT OR TELDISTRICT UP TYPE FIRE} ESSED BY * O NOTICE O A PLIC NT:,If; after makingthi ertificate of ENGINEER- NO. CONST. ZONE � Exempption,.you should become .subject to the Workers' Q. ` a Compensation provisions of the Labor Code; you must forth ADDRESS ©(/ iUUJCCC.��� with comply with such provisions ,or this permit;.shall be TEL. N P Y P P K l t Y,D 1/" STATISTICAL CLASSIFICATION, APT. CONDO. Z deemed revoked. CONTRACTOR t� W �/1 NO. . � - � _ LICENSED CONTRACTORS DECLARATION: LIC.- CLASS NO. DWELL: UNITS I hereby affirm that I am licensed under provisions of.Chapier,9 ADDRESS NO. (commencing"with Section'7000)'of Division-3 of the Business LIC. SEWER MAP and Profess ians.Code,and my license is in full force and•effect. CITY. CLASSgK. PG. VALIDATION SQ. FT. NO. OF NO. OF CHECK.+ . License.Number' �'Lic.'Class SIZE STORIES_ FAMILIES ONE L DESCRIPTION OF WORK NEW Contractor Date ❑ - VA UATION ! ,. ..ADD ❑, $• ❑I am exempt under Sec. c ALTER El B.&P.C. for This reason $ USE OF REPAIR Dater EXISTING BLDG. DEMOL ❑: Signature APPLICANT' TEL. FINAL . OWNER-BUILDER DECLARATION (PRINT). NO. _A' DATE /J . a. .. I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL r ' Professions Code): ' PRESENT _- By r)t S I o$ BUILDING ClC �j /y���' _ JJ " 1, as owner of,the property, or my employees with ADDRESSr' ' " u I(� ltL o JZ I wages as their sole compensation,will do the work and LOCALITY :. .G the structure is not intended or offered for sale'(Section 7044,Business Business and Professions Code.) MOVING TEL D V t t ^p ❑ "I, as owner of the.property"--cm exclusively contracting CONTRACTOR NO. t -'rri 1 �, _a :with licensed contractors to construct the project (Sec- ADDRESS ;' t=F'. 'Cf.50 tion 7044, Business and Professions Code.) H � JE _ REQUIRED TOTAL SETBACK FROM EXIST. 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. f _I1_# ISI pf (Sec. 3097, Civ. C.). :SIDE,. :!' �1�L, 1976' a Lender's Name r �• {DMA Ref. It Lender's Address P.C. Fee$ Permit Fee 0, 0 0. � - - D o I certify that I have read this application and state that the Issuance Fee, LDMA'P/C# aboveinformation is correct. I-agree to comply with all County Irivestigation'Fee 8 ordinances and State laws relating.to.building construction, Total Fee �/ LDMA Perm. It a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection'purposes. ' C re_a SEE REVERSE FOR EXPLANATORY LANGUAGE ' Signature of aplicant or Agent ate