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Home My Public Portal About4973 LOMA AVE_Building__ .�N DECLARATION .- M'nsi Tree, oraaf lertif airmtte-of Workers' Compensat on Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Seca 3800, Lab. C.)`' - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. - Company F1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified-copy.isfiled with the county building inspec- BUILDING �° . tion deportmnt-. ;� ADDRESS Qr/ • A Dotr� Applicant J CITY ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' / p�a . OF BLDGS. ,�p NEAREST / COMPENSATION INSURANCE SIZE OF LOT DI OW ON LOT _J__ CROSS ST. (This section'need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK I LOT NO. MAP BOOK'' PAGE PARCEL n ,� TEL. ,�, USE ZONE MAP certify'that in the performance of the work'for which this OWNER NO. I NO. >_ permit is issued, I shall not employ any person ih any'manner SPECIAL IL so cis to become subject to the Worker ' ompensation LawADDRESS a' CONDITIONS U Dot� M Applicant ` CITY ZIP NOb E TO APPLICANT: If, after making this CertificateA�af ARCHITECT OR DISTRICT GROUP TYPE FIRE PRO•ESSED BY._ Exemption, '.you should become subject to the Workers' ENGINEER O• v��1( P.q/ CONST. ZONE Compensation provisions of the.Labor Code, you must forth- ADDRESS /i V. W 1 v 9L with comply with`.such provisions or this permit shall be EC. STATISTICAL CLASSIFICATIONAPT. CO O. z deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. �' DWELL.UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and _. t LIC. SEWER MAP Prefessions,Code, and my license is in full force and effect. CITY CLASS BK VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION DESCRIPTION OF WORK 645t lu 10 k) NEW ❑ O 1� 0 Contractor Date ADD E FT I am exempt under Sec. , •� ALTER ❑ B.BP.C. for this reason 1 '�/ REPAIR ❑ $ 3 0A 2 A Date: USE OF BLDG. DEMOL EXISTING ❑ _ # © o 0 0 0 1 Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE hereby affirm that I am exempt from the Contractors License 1 0 1 43.6 3 Low for the following reason (Section 7031.5, Business and ADDRESS FINA ' -Professions Code):' PRESENT BY o a BUILDING I, as owner of the property, ormy employees with ADDRESS / r, 1 —' 85 - wages as their sole compensation,will'do the work and \.' O.O the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. OCONTRACTOR NO. I, asownerof the property, am exclusively contracting with-licensed contractors to construct the project (Sec- j � ✓ '� tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL SETBACK FROM T. 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. # Lender's Address P.C.Fee$ Permit Fee /31 j a I certify that.l have read this application and state that the Issuance Fee L, LDMA P/C# -- a above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, _ Total Fee h LDMA Perm. # v and hereby authorize representatives of this County to enter m upon a bove-mentioned prope y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 'Signature t Applicant or Age Date