HomeMy Public PortalAbout5752 LOMA AVE_Building__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have certCom a of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance, �
or a certified copy thereof (Sec. 3800, Lab. C. -
COUNTY OF LOS ANGELES BUILDING AND SAFETY �
Policy No. Company BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING /:.'7 Z /J� � , /(./I A')E E .
tion department. ADDRESS // 5 d `� , l ✓ LOCALITY
„^/JKE NEAREST
Date Applicant CITY II p NOZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' �() 1C [Qf 'NO-OF BLDGS.ON LOT ASSESSOR
SIZE OF LOT
COMPENSATION INSURANCE MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars ($100)or less.) TRACT �,f /�(BLOCK /SLOT NO. �j NO.
I certifythat in the performance of the work far which this OWNER k f V� (i NO. ✓ J CONDITIONS A.
P "DISTRICT GROUP TYPE FIRE PROCESSED BY
permit is issued, I shall not employ an s in any manner S 2- /V. CONST. Zq
so as to become subject to the Worker '• pensation LaWs. ADDRESS �yr / / ( ✓-fi
Date Applicants CITY PLS. 1. [ ZIP 17 780 '�, O
/ ARCHITECT OR / r�/� Q�( EL STATIS ICAL CLASSIFICATION APT. CONDO. U
NOTICE TO APPLICANT: If, afte snaking this Certificate of ENGINEER / �//G' �1l° 6 -u l CLASS NO. ��
DWELL. UNITS NJ
Exemption, you should become subject to the Workers' nd /
Compensation provisions of the Labor Code, you must forth- ADDRESS `a3� SCJ O/io?' SEWER MAP
II �
with comply with such provisions or this permit 'shall be ��'�7` g
deemed revoked. EOCy! V/ ,`• VALIDATION
CONTRACTOR BK. PG,
LICENSED CONTRACTORS DECLARATION LIC. y Q �[�
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS . /y NO. Z O 0 V 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 VA CLASS $ •J 000
000.SQ. FT. NO.OF NO. OF HECK
License NumberO&0//r� Lic.ClassSIZE STORIES FAMILIES ONE
Contractor
�� �f u�d�-l� Date I e V-' DESCRIPTION OF WO Q NEW ❑ $
ADD
❑ I am exempt under Sec. ALTER ❑ FINAL
B.BP.C. for this reason
REPAIR E] DATE
Date: USE OF FINAL
EXISTING BLDG. C/ DEMOL ❑ B
Signature
APPLICANT TEL. Y
OWNER-BUILDER DECLARATION PRINT NO.
I hereby affirm that I am exempt from the Contractor's License 00 '�f
Law for the following reason (Section 7031.5, Business and ADDRESS t�5F
6 7,
Professions Code): PRESENT
❑ BUILDING o 0 0 0 l
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
r' the structure is not intended or offered for sale(Section LOCALITY v 2 Q 6.7
7044, Business and Professions Code). MOVING TEL.
I, owner of the property, am exclusively contracting CONTRACTOR NO. G j i
with licensed contractors to construct the project (Sec- ADDRESS ! i
tion 7044, Business and Professions Code). CG 1' G `J
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 /►� �Of J U/ ,
the performance of the work for which this permit is issued P.L. (J
(Sec. 3097, Civ. C.). SIDE Ir C,� ( iq0/
P.L.
< Lender's Name
P.C. Fee$ Permit Fee
Lender's Address
I certify that I have read this application and state that the Issuance Fee • V L/
above information is correct. I agree to comply with.all County Investigation Fee ,n r
ordinances and State laws relating to building construction, Total Fee
u and hereby aut rize representatives of this County to enter
m upon ` -mentioned property foinspection purposes.
a ��p �j
-4 SEE REVERSE FOR EXPLANATORY LANGUAGE
�� Signature of Applicant or Agent Date Os