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HomeMy Public PortalAbout5736 LOMA AVE_Building__ WORKERS' COMPENSATION DECLARATION S ra`i�tirm that I.have a certificate , consent to' self „ ' APPLICATION F { `• �_J I L®I IV C� �P E RM I T 4 'insyre, ora certificate.of Workers' Compensation Insurance, or a�errifjed copy�thherreof (Sec. 3800,•Lab. C:) '. BUILDING AND SAFETY • Policy-, � 5--.s_ompany ��r'�"�"`ai COUNTY OF LOS ANGELES ❑ deriified,copy is hereby furnished. FOR APPLICANT TO FILL IN" ADDRESS • , � _ DING ' _ Certified copy is filed with the county building inspec- -. suagwG aD .�tn � ADDRESS J tion depart/yCment. Date 4"'A ' scant R�3 S �� CITY' ZIP { "� O LOCALITY Pp NO. OF BLDGS. ' NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE.OF LOT NOW ON LOT CROSS ST. (� COMPENSATION INSURANCE .." SSOR (This'section need not be completed if,the permit is for one TRACT BLOCK LOASSE T NO. MAP BOOKgs2P/,, AGE � vARCEL9,/�� hundred dollars($100) or less.) • Q �l��'pp TEL. r� //� 2 vv�� OWNER �F-+ �rG�C7 NC .�IP 73� USE ZONE OP S 1 certify that in,the.performance of the work for which this .. SPECIAL } permit is issued, I shall not employ any person in any manner' ADDRESS ' �: ® "m CONDITIONS a so as.to become subject to the Workers' Compensation Laws. iZ fo 0 CITY �� ZIP 7 Date - Applicant- ARCHITECT OR p� TEL./',/ DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: df, after making this Certificate,of ENGINEER MAI t--V'` N0.71'�/,�dY2� CONST. "ZONE F- Exemption, you should become subject. to the Workers' ADDRESS b bNOV �I"^' J�J ut' . •Compensation pr ovisions.of'the Labor Code, you must forth- ` N with comply, with such,proJisions or this permit shall be TEL ,` STATISTICAL CLASSIFICATION APT.LCqN.DLOdeemed revoked:, CONTRACTOR I�tI �� NO.��'/(PZ LICENSED_CONTRACTORS DECLARATION• LIC. CLASS NO. a'� DWELL. UNITS - LICENSED hereby affirmihat I am licensed under provisions of Chapter 9 ADDRESS �� NOS SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. CITY P�'f1l�jll G.� CLASS VALIDATION and Professions Code,'and my.license is in full force and effect. BK. F. SQ. FT.' NO. OF NO. OF CHECK License Numbe j� Lic. Class rf _q SIZE /1 STORIES FAMILIES r ONE VALUATION �s)�a`j�tl � ySDate T I DESCRIPTION.OF'WORK NEW ❑ a Contractor l tJ I Q J tY' W D©li• :ADD ❑ ❑I am exempt under Sec. ALTER ❑ B:'&P.:C. for this reason 11i REPAIR ❑ $ Date: USE OF 11 �( DEMOL ❑ EXISTING BLDG. � �O Signature APPLICANT• TEL'. ` FINALS 9 (PRINT) i� � v. NO: fP Q 7 OWNER-BUILDER DECLARATION. DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS Afle� ex` � �' cN'9" FINA - Law for the following reason.(Section 7031.5, Business and Professions Code):. PRESENT BY ,7t:. _ x BUILDING _ - '❑ I, as owner of the property, or my.employees with ADDRESS wages as their sale compensation,will do the work and LOCALITY. ® e� 5 �1 t': " the structure is not intended or offered for'sdle(Section - • 7044, Business and Professions Code.) MOVING- TEL ' ❑ CONTRACTOR NO. •I,as owner of the property, am exclusively contracting with-licensed contractors to construct the project (Sec- ADDRESS t_ d•'�` ' tion 7044, Business*and Professions Code.) !,LP - !s t t REQUIRED. TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK : YARD HW PROP. LINE WIDTH ` ••i s* I hereby affirm that there is a construction lending agency for FRONT the performance'of the work for which this permit, P.L. (Sec. 3097, Civ. C.).. P SIDE r P.L. �? M1 t st .war Lender's'Ngme, P C. Fee$ Permit Fee LDMA Ref. # !. Lender's Address o� 7 a I certify that I have read thjs application and state that the Issuance Fee LDMA P/C# _ 8 above information is correct. I agree to comply with all.County Investigation Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm:# a, and hereby authorize representatives of this.County to enter upon the,above-mention property for inspection purposes: •o /�;�y..o,wl,1 � yyrq" S/'��� ` SEE REVERSE FOR EXPLANATORY LANGUAGE - Signature of Applicant or Agent Date - -