HomeMy Public PortalAbout9156 JAYLEE DR_Building_12/17/1991_demo of fire damage WORKERS' COMPENSATIONDECLARATION
I,here.bo affirm •!hat I have r certificate of consent to self
nsvr or 8 certificate of Workers' Compensation Insurance,
or a certified copy thereof,(Sec'. 3800, Lab. C.)_
9i., COUNTY'OF LOS,ANGELES' BUILDING-AND-SAFETY
Policy No.67j,485a'Compan- - il,rt �rlw�
❑ ` Certified co is he�eb furnished. FOR-APPLICANT TO FILL IN BUIiDING
PY. . Y ADDRESS g r E L �. .o 2.
Ll� Certified copy,is filed with the-co unty building inspec- " UILDING '- �r
Tion department. '.,ed110uS CQu5�Le ADDRESS f S� -� ,:,.�H L �Et . ��� C J; cev7 .
,
IJ Cw7UT.v,n[�,_ CITY- 1-QvM Le:. -llY ZfP. LOCALITY,
Date Applicant NO. OF BLDGS. NEAREST- •'
C RTIFICCOMPENSATION INSURANCEPTIONORKERS' •' SIZE OF LOT NOW ON LOT,,FRCM , CROSS ST.
u
-. t- ASSESSOR X �y
(This section need not be completed if-.the permit.is for one TRACT' BLOCK LOT NO.,
MAP BOOK .,,/ L�i�- , PAGE O� PARCEL ate✓ '
hundred dollars ($100) or less ) TEL.
.. GF�s l� �0^"Is N0�
OWNER �i1I
I certify that in the performance of the'..work for•which this p
/ 1 USE ZONE MAP
permit is issued-, I shall not employ any person,in any manner ADDRESS �` L'e 14 L t-c. '� d
NO.
so as to become subject,to the.Workers' Compensation:Laws: O'
SPECIAL
CONDITIONS •
CITYZIP
Date AppCie
licant,- .f ARCHITECT OR ' TEL. DISTRICT GROUP 'TYPE• 'FIRE PROCESSED'BY O
P APPLICANT: If, after makiri this Certificate of TTT ENGINEER NO.
9 CONST: ZONE 0
CE
Com ptio.n� you •should-...become subjecT to 'the Workers' .` >; U
EOmpens,tion provisions of the Labor Code, you-must forth- ADDRESS ,.. �� ,/
P Y , N>
with comply with such-provisions or this permit shall -be TEL: , STATISTICAL CLASSIFICATION APT. CONDO.
/ Q
deemed revoked... ONTRACTOR.(.o t I I u'5 �..�- 9 NO. / -63'7q Z
LICENSED-CONTRACTORS DECLARATION, LIC. / CLASS NO. DWELL. UNITS
I hereby affirm'that'1 are licensed under provisions of Chapter.9 „ ADDRESS L` [ ;ro Py,• NO. q4561LA
(commencing with Section 7000)of Division 3 of,the Business LIC. p SEW
CITY• I�°IJ�O01/� CLASS ff�yl �y�� �j
and Professions,Code,and my license is in full force and effect. - BK:E/s PG` 7 VALIDATION
SQ.,FT. NO. OF NO. OF CHECK
License Number-+ !. ' Lic 'Class ` S ONE
SIZE STORIES FAMILIES /
aa
' ct'�
/�
VALUATION
Contractor �I"•+ZS- �iz °� Date DESCRIPTION'OFWORK .f{tCilE�rl4 b/dvYar3t6`,ey NEW ❑ r
.,• ADD ❑ $ D'
❑I am exempt under Sec. D �i_ rw .�'.
ALTER ❑
B.&P.C. for this reason REPAIR $
Date: .
USE,OF
00A-
` nvQ i : EXISTING BLDG.' DEMOL
Signature.`\' o�`� APPLICANT
TEL: FINAL
OWNER-BUILDER DECLARATION .. (PRINT) NO: ��Z1
I hereby affirm that I am exempt from=the Contractors License DATE_
L
Law for the followinss g.reason (Section'7031 5; Busineand' ADDRESS FINAL' L
Professions Code) PRESENT •- - - ey <
BUILDING
❑.. 1, as owner of-the property, or my.employees with ADDRESS
wages as their sole compensation,will do the-work-and
the structure is not intended oroffered for sale(Section LOCALITY w
7044, Business and:Professions Code.), : �C\ MOVING ?EL: �E
❑ , 1, as owner of the property, am.exclusively contracting. n1 CONTRACTOR NO.
with licensed-contractors to c6hWuct:the project.(Sea
ADDRESS
tion 704.4, Business and Professions Code.:) t 4S
0 REQUIRED TOTAL SETBACK FROM EXIST.
• CONSTRUCTION LENDING AGENCY SET BACK YARD ' HWY' PROP: LINE WIDTH :
`.t,
I hereby affirm that there is a.construction lending agency for FRONT :
the-performance of the work.fo'r•which this.permit is,issued ' ' 'P.C'.
(Sec:3097, Civ.'C.), SIDE -
-P.L.
Lender's Name, LDMA Ref. #
P,C. Fee$ Permit Fee ",
Lender's Address .
a I 'certify that I have read this application and-state that the Issuance Fee LDMA P/C# D
8 above information is correct. I agree to comply with all County Investigation Fee /
a ordinances and State laws relating to,building construction, Total Fee /pL LDMA Perm. #
a and hereby authorize representatives'of this County to enter
u n the above=mentioned'properfy for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent - - Date -