The URL can be used to link to this page

Home My Public Portal About5753 LOMA AVE_Building__ WORKERS' COMPENSATION DECLARATION I`here;y -jffirm that I have a certificate of consent to self 'insure, or a certificate of Workers"Compensation Insurance, APPLICATION. FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) y- y�- /•�' COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company .5/ / e %/I rJ9 Certified copy is herebyfurnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS \� ®� Certified copy is filed with the county building inspec- BUILDING ! tion department. ADDRESS L ^� 0 > Dated A5 Applicantir A CITY Ied/l �:� 0 7 ZIP LOCALITY Y CERT FICATE OF EXEMPTION FROM WORKERS' l �•� NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT D CJ NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO, MAP BOOK PAGE PARCEL 'e TEL US ZONE MAP I certify that in the performance of the work for which this OWNER !J! �. NO. NO, permit is issued, 1 shall not employ any person in any mannerI SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS U CITY ZIP Date Applicant ARCHITECT OR TEL. DISTRICT GR UP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. Exemption, you should become subject to the Workers' -tI CONST. NE U Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be , �, TEL. D STATISTICAL CLASSIFICATION APT. DO. N deemed revoked. CONTRACTOR_aW eJe C4 05 NO. �O �/ LICENSED CONTRACTORS DECLARATION LI CLASS NO. DWELL. UNITS — I m I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS fi' -L'��e ld SEWER MAP (commencing with Section 7000)of Division 3 of the Business and / y�/1 LIC, Professions Code, and my license is in full force and effect. CITY 1 IWD 1 CLASS BK LPG. L VALIDATION a SQ. FT. NO.OF NO.OF CHECK It License Number 347 /13 Lic.Class L! SIZE � STORIES � FAMILIES � ONE r -a DESCRIPTION OF WORK �� —� NEW C] s VALUATION Contractor Date -� ® ,J ADD I am exem t under Sec. ❑ , ALTER B.BP.C. for this reason © REPAIR $ 'Date. USE OF EXISTINGBLDG. to C. , DEMOL p 9 5 7.0 A Si nature i� APPLICANT �+ �' FINAL Signature— TEL•OWNER-BUILDER DECLARATIo PRINT �. .�%/�) %'� NO. DATE — # 0 0 0 0 0 '� I hereby affirm that I am exempt from the CoFFFFFF tractor's License Law for the following reason (Section 7031.5, Business and ADDRESS ?asee 6a "y Yt `FIN I o 1 5-a O 0 Professions Code): PR N BY ZZ = OBUILDING o o,� 5 J O O V I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and 05 88 I Y ,ry LOCALITY (7 is not intended or offered for sole Section _ the structure ( 7044, Business and Professions Code). MOVING TEL. - aCONTRACTOR NO. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY ED SETT REQUIRED YARD HWY TOTAPREOTPAINEFR WIDTH I 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. # ' Z P.C. Fee$ Permit Fee �J Lender's Address 3 g I certify that I have read this application and state that the Issuance Fee r.� LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee 0 LDMA Perm. # o and hereby authorize representatives of this County to enter upon the obove- entiorped prl�perty for inspection rposes. e�J�/�it 9r .S '7ry SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or A nt 9 PP 9