HomeMy Public PortalAbout9734 LEMON AVE_Building__ WORKERS' COMPENSATION DECLARATION t
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
r or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No: Company
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN ADDRESS 7�j
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS 77
Date Applicant CITY Ayr, ZIP /1190 LOCALITY , 1 t
CERTIFICATE OF EXEMPTION FROM WORKERS' 1� NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIE F LOT`Ir NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one U,.f J1 aASSESSOR
hundred dollars ($100)or less.) TRACT L{� a•0 BLOCK ��� LOT NO. MAP BOOK PAGE PARCEL
TEL. USE ONE MAP 7
OWNER
I certify that in the performance of the work for which this a NO. 0 NO.
permit is issued, I shall not employ any person in any manner Z� S1,4 I SPECIAL
so as to become ubject to the Worker�Copens aw . ADDRESS � CONDITIONS 0
CITYrCA ZIP 11004
V
Date Applicant !Y
NOTICE TO PPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PRO SSED BY 10
i ®, / /)
Exemption, you should become subject to the Workers' ENGINEER NO. CONST. ZONE
v
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this,permit shall be ADDRESS
deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. JI[CONDO. to
CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of-Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY CLASS BK 22-17 VALIDATION
SQ. FT. NO.OF NO. OF CHECK
License Number Lic.Class SIZE ISTORIES FAMILIES ONE
D VALUATION
Contractor Date DESCRIPTION OF WORK a.c I ADD NEW 1:1s 7 2 4 3 A
r� ❑
❑ I am exempt under Sec. ALTER ❑ # o o 0 ?.a
B.&P.C. for this reason REPAIR ❑ $
-.- 6050
Date: USE EXISTOF 1 iNG BLDG. $ (� DEMOL o - 60.5,0'
Signature APPLICANT �,/ TEL. FINAL 5`e+$']
OWNER-BUILDER DECLARATION PRINT �� /� /1��, NO. DATE ��-- 'L f p 6
1 hereby affirm that I am exempt from.the Contractor's License /
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT BY >'
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property, am exclusively contracting CONTRACTOR NO. ,I
with licensed contractors to construct the project (Sec-
tion7044, Business and Professions Code). ADDRESS
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
LDMA Ref. #
P.C. Fee$ Permit Fee
Lender's Address /1
o I certify that I have read this application and state that the Issuance Fee �C/. LDMA P/C#
o above information is correct. I agree to comply with all County Investigation Fee + �j
0 ordinances and State, laws relating to building construction, Total Fee / A y LDMA Perm. #
and hereby authorize representatives of this County to*enter
m upon th ov - en i ed ro for inspect' n p ase
i�- ,
L SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date -