HomeMy Public PortalAbout9179 JAYLEE DR_Building_7/8/1996_roof repair WORKERS',COMPENSATION DECLARATION
I hereby affirm that I have r certificate of consent'to elf � P P �C A u d G H P a R u d L D d H G [P� n'n d u
insure, or a certificate of Workers''Coinpensation Insurance, � Lr'111J LI LSU LI�1. LI LI\1Ul/U
or acertified copyahereof (Sec. 3800, Lab. C.) COUNTY-OF LOS ANGELES - BUILDING ARID SAFETY
Policy No. Company
F-1 'Certified,copy.is hereby furnished.• FOR APPLICANT BUILDING'
TO FILL IN ADDRESS 7
El. Certified copy is filed with the county building inspec- BUILDING <:/ /
tion department. ADDRESS"T / 7 G,
Date_ Applicant CITY' / G� Fr^ ZIP J C/, LOCALIT
NO. OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS': SIZE OF LOT >- NOW ON LOT CROSS ST.
COMPENSATION INSURANCE
(This section'need not be.completed if the permit i's for one TRACT - BLOCK " LOASSESSORT.NO. MAP'BOOK PAGE PARCEL
hundred dollars.($100) or less.) ` TEL. �
✓ USE ZONE MAP:
I'certify that in the-performance,of the work for.which this = ` NO.
permit is issued, I shall not employ,any.person many manner ADDRESS �� JdL Q_ Y' SPECIAL _ h
CONDITIONS
so as to become subject to the Workers',Compensation Laws. !/
0
CITY
P �� ! 4 . U
7
h zip-:
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, _after makingthis Certificate:of- ENGINEER NO. .:DISTRICT „GROUP TYPE FIRE _ CESSED BY
' CONS ZON F-
Exemption; you,.should become:,subject 'to the,Workers' j�� `Q w
Compensation provisions of The Labor Code, you.must forth- ADDRESS -'' </ / .
with comply ,with .such provisions,or,this permit shall be TEL. STATISTICAL CLASSIFICATION APT:.. CONDO. Z
deemed revoked. :: CONTRACTOR NO. _
LICENSED CONTRACTORS DECLARATION, t LIC. CLASS NO. DWELL. UNITS
.I hereby affirm'that I am licensed under provisions of Chapter 9 ADDRESS �J NO. =BK
MAP
(commencing With.Section 7000);of Division 3 of the Business J LIC.
and Professions Code,and myaicense is in full force and effect: CITY CLASS pG VALIDATION
SQ.-Ff. NO. OF NO. OF CHECK
License Number' Lic. Class SfZE , r�a STORIES FAMILIES ONE
k VALUATION•
Contractor Date DESCRIPTION OF WORK NEW $/�dD� �(�• - ;-
)ADD' D
❑I am exempt under Sec. A',jyFt
ALTER ❑
B.&P.C."for this reason REPAIR ❑ $
Date:
USE
OF -
- EXISTING BLDG. DEMOL'❑
• Signature APPLICANT TEL. FINAL
q,
OWNER-BUILDER DECLARATION :. (PRINT) Np.
I hereby affirm that i am exerript.from the Contractor's.License DATE
Law for the following reason_ (Section 7031.5, Business and ' ADDRESS FINAL
Pr essions Code) PRESENT -
BUILDING BY ACCT.6
I, as owner•of the property, or my employees with ADDRESS � a
wages'as their sole compensation,will do the work and - } �� 1Y„}"u
the structure is not'intended or �offered for sale(Section LOCALITY i ITEMS r
7044, Business and-Professions Code:)- MOVING TEL. 1 ITEI tS
CONTRACTOR NO.
❑ I, as owner of'the property,.am".exclusively contracting --•q�•.
with licensed contractors to,construct the,project (Sec- ADDRESS. TOTAL. o`er' —,315'
15
tion 7044,'Business and Profess ions:Code.) i c
`;REQUIRED'. TOTAL SETBACK FROM . EXIST. CASH 109 n*7'}
CONSTRUCTION LENDING AGENCY SET BACK YARD' "HWY PROP. LINE WIDTH
I hereby affirm that there,is a construction lending agency for FRONT CHANGE _00
the performance of the-work•for'which this permit''is.issuecl PAl
(Sec. 3097, Civ. C.). SIDE
PA
Lender's,'Name, 0000-000-1, 7l �G.r!q6
:. LDMA Ref. # -,�-,. _��
1 t
V=1
P.C. Fee$
Lender's Address Permit Fee ® O i PM c'a 32
1 certify that i have read this application and state that the Issuance Fee LDMA P/C# D
o '
8 above information is correct. I agree to comply with all County Investigation.Fee
ordinances and State laws relating to building construction, Total Fee D�r� LDMA Perm. #
R and hereby authorize representatives of this County to enter
upon the ab :men ' ned ro rty for inspection purposes. '
a
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnatufe ofApplicant Agent " Date