HomeMy Public PortalAbout9208 LIVE OAK AVE_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers'Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
E. Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS r
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS LOCALITY
C� n
NEAREST
Date Applicant CITY �° ZIP CROSS ST.
10
CERTIFICATE OF EXEMPTION FROM 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 FMAPhundred dollars ($100)or less.) TRACT BLOCK LOE NO.L.I certify that in the performance of the work for which this NER Q NO. NS
permit is issued, I shall not employ an person in an manner DISTRICT GROUP TYPE FIRE PROCESSED BY Ilk
P P Y Y P Y ADDRESS Q � CONST. ZONE
so as to become subject to the Workers'Compensation Laws. 0
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Date Applicant CITY ZIP STATISTICAL CLASSIFICATION ;. T. CONDO. U
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.
ENGINEER NO. CLASS NO. DWELL. UNITS @�
Exemption, you should. become subject to the Workers' Nl
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP g
with comply with such provisions or this permit shall be TEL,
deemed revoked. _ CONTRACTOR NO. BK PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION
(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 $ laC�Za
SQ. FT. NO. OF NO. OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
/ NEW
Contractor Date 0 $ r
DESCRIPTION OF WORK ( 112
/c/�
I am exempt from the licensing requirements as I am a �y. - DD
licensed architect or a registered professional engineer ALTER FINAL
actin professional capacity Section 7051, b
g in m Y P P Y ( � REPAIR � DATE
Business and Professions Code). USE OF r c FINAL
EXISTING'BLDG. fle. i9w v, DEMOL B
Lic. or Reg. No. Date APPLICANT EL. Y
OWNER-BUILDER DECLARATION (PRINT) NO.
I hereby affirm that I am exempt from the Contractor's License D /
Law for the following reason (Section 7031.5, Business.and ADDRESS
Professions Code): PRESENT
❑ BUILDING
I, as owner of the property, or my employees with I ADDRESS
wages as their sole compensation,will do the work and
5 1
the structure is not intended or offered for sale(Section LOCALITY
-�
7044, Business and Professions Code). MOVING TEL. 5 A
I, as owner of the property, am exclusively contracting CONTRACTOR NO. # 0'0'0'0 0 1
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). 2. ° 1 3 3,0 0
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 -:0 1 313 0 0 5
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE 0 8 1 1"-82
P.I.
Lender's Name
P.C. Fee$ Permit Fee
Lender's Address
w I.certify that I have read this application and state that the Issuance Fee
above information is correct. I agree to comply with all County Investigation Fee i
10 ordinances and State laws relating to building construction, `
Total Fee
and hereby o rize r resentatives of this County to a ter
a upon a ve- enti ned prop ty for inspection purp es.
a SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Appli nt r gent - Date Os