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HomeMy Public PortalAbout9168 JAYLEE DR_Building_1/27/1982_swimming pool WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self Ano n,[P��.0 � O M FOR M P E R nn�U insure, or a certificate of Workers'Compenstion Insurance, or LY�1 LI Ll L/�� U V U�1 LI V LI UULI V U a certified copy thereof (Sec. 3800, Lab. jC. ' COUNTY OF LOS'ANGELES BUILDING AND SAFETY Policy N-=':—Company BUILDING Certified copy is hereby furnished.. - -'FOR APPLICANT TO-FILL IN ADDRESS Certified copy is filed with the county building inspec BUILDING tion department. ADDRESS �a iLG LOCALITY p NEAREST Dote 1�''7ll�. ,Applicant CITY ZIP CROSS ST. CERTIFICATE OF EXEMPTION FR&M WORKERS' NO. OF BLDGS. ASSESSOR ,� COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL •This section need not be completed.if the permit is for one USE ZONE MAP �. ,undred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. 0 Iq� /�y - TEL. SPECIAL d I.certify that in the performanc f the work for which this. OWNER K..f/ NO. 'CONDITIONS _ o . 1, �� DISTRICT GROUP TYPE FIRE PROCESSED BY V permit is issued, I shall not oy any p n in any manner ADDRESS �p CONST. ZONE so as to become subject t t Work Compensation Laws. fzC ._ CIT ZIP 0 Date p i nt STATISTICAL CLAS FICATION APT. CONDO. O NOTICE. APPLdCANT. after m kin this Certificate of ARCHITECT R TEL. g ENGINEER ��� NO. CLASS NO. DWELL. UNITS tL Exemption, you' sh d beta a subject to 'the Workers' Compensation pr isions of the Labor Code, you must forth- ADDRESS d �-3 SEWER MAP wi h compI ith such provisions or this permit shall'be ., TEL. VALIDATION d erred yoked. CONTRACTOR NOt� ;�ij BK. Af PG, LICENSED CONTRACTORS DECLARATION• LIC. 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRES`_4-8� >4i NO. � VALUATION (commencing with Section 7000)of Division 3 of the,Business and LIC. / f Professions Code, and my license is in full force and effect: CITY y 9a1O�? CLASS �� $ SQ. FT. �1c� NO:OF' NO. OF CHECK License Number T� 'Lic.Class� -3 • SIZE �/✓ STORIES FAMILIES ONE -�yX 7 O,r` NEW _ $ Contractor Date DESCRIPTION OF WORK ElI am exe pt from the licensing requirements as I am a f ADD „ r licensed architect or a registered professionol'engineer ALTER O FINAL p acting in -my professional capacity (Section .7051, REPAIR DATE Z�j ?/ 7� z 27,!5.5.A .Business and Professions Code). USE , FINAL f EXISTING BLDG. DEMOL 'a By �T #:0 10 0 l0 2 Lic.or Reg. No: Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) " " NO. l/ Z io o G.'U 5 2 I hereby'affirm that I am exempt from the Contractor's License / J Law for the following reason (Section 7031.5, Business and ADDRESS o,o 0 4W 5 2 c=.) Professions Code):, PRESENT aBUILDING 01.2 7L 8 2 . I, 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 or offered for sale(SectionLOCALITY - 7044, Business and Professions Code). MOVING TEL. ElI,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 EXIST. 2 7,5 b A CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH z 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 #'o 0 0 0 0 (Sec. 3097, Civ. C.). -SIDE Lender's Name 7i l P L 2'0 0 $8, yob . Lender's Address P.C.Fee S Permit Fee °.° ° 8.a'Q Q I certify that I have read this application and state that the Issuance Fee :� - 12 7'—8 2, above information is correct. I agree to comply with all Count 9 PY Y Investigation Fee- ordinances and State laws relating to building construction, Total Fee and hereby authorize representatives of this County to enter upon the above- oned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dote - ©s