HomeMy Public PortalAbout6411 LOMA AVE_Building__ v r -
Eby v ORm otCO av !U certificate ate of con* ent r a a . ' ®I PERMIT.
a , r
-
o self . �O t G'.
e, or a certificate of Woikers Compensation insu ante,
or'a certified copy thereof (Sec. 3800, Lab. C') -
- •: COUNTY.OF LOS ANGELES BUILDING'=AND SAFETY
Policy No. Company a
Certified copyis hereby furnished.. FOR-APPLICANT TO FILL IN vBDOREss
Certified copy is filed with'the county building inspec BUILDING
tion department: ADDRESS L,• / /GL
Date"' Apphcanh CITY �( ZIP / �J LOCALITY
CERTIFICATE OF-EXEMPTION FROM WORKERS' L: SIZE`OF LOT' �� '/ " NOW ON LOT L - CROSSSST. ' ~
_
COMPENSATION INSURANCE•. '°
(This'section,neednot be.completed-if the permit is for-one - - _... _ - ASSESSOR 4
TRACT. BLOCK LOT NO. // MAPBOOK" PAGE` PARCEL
'� / NO. ZP4� ,
hundred dollars ($100)or less.)
USE ONE MAP
II certif that in.the erformanpce6 f,t�P work for.�hich this OWNER s� �G NO. ;
Y P
•ermit is issued, I shall not employ an erson in-an manner /' _ SPECIAL - -
_... ADDRESS--4�o Z/ 1 G _ __. _ CONDITIONS nk
so as to become subject`to the Workers''Compensation Laws
ZIP.
Date /L-P/ Applicant'/�1 .y .._ _
NOTICE TO APPLICANT: If, after making this Certificate of
ARCHITECT OR TEL. DISTRICT GROUP .TYPE _'_ -- „_FIRE PRO SSED BY .
IL
Com ensation rovisions.of the Labor Code;:you must Workers ENGINEER O LU
LU
wxieh comply:with vimption; you. sion of,t s onssor.;ehis tothe.
shallorth ADDRESS -
C NST,/. ZONE
such
P P Y � .V .. V
bem __ .._. _ ._: ,__... _. _
deemed'revoked. TEL. STATISTICAL CLASSIFICATION APT: F
ON O.
CONTRACTOR. NO. _ _
LICENSED CONTRACTORS DECLARATION.:., - LIC. '' -
CLASS NO:�DWELL. UNITS
I hereby affirm that I,am licensed under provisions of Chapter 9 ADDRESS / NO. r
(commencing'with Section 7000)of Division 3_of the Business and
SEWER MAP
Plr`ofessi Nu"bee,'clnd my license is in full force and effect. CITY. CLASS ON
BK. PG. VALIDATION-
SQ.
SQ. FT. NO. OF NO,OF CHECK
L ce Lic.Class - - - -- b,
SIZE e�JG STORIES_. l FAMILIES /` ONE
V
' DESCRIPTION OF-WORK'' - - _-- .NEW.. _
ALIIATION
Contractor Date ADD ® $
I am exempt under Sec ZOr v - ALTER
B.BP.C. for this reason--
-REPAIR.-
USE
EPAIR._
- Date: >. USE OF ' DEMOL ❑
EXISTING BLDG. -
_ APPLICANT TEL.
I.hereby affirm that I:am exempt from,the FINAL
Signature
OWNER-BUILDER DECLARATION PRINT) /� / ,/i ,NO b� Gi�G DATE -- -
e Contractor's License .�6 3 3 A
Law for the following reason;(Section 7031.5, Business and ADDRESS INA f
- _
Professions Code): PRESENT __ .-.- .. gY: ..
#.0 0 0 0•,0�1
NG
I, -as owner of the property, or my employees with ADDR SS 1 4 T i+ �r O 1 0 6 1 3
�.. - }
wages as their sole corriperisation,will do the work and _ - t 3 • ' +�,o 0 1 b..l 3
the structure is-not' ntended or offered for sale(Section LOCALITY Ilk-
- i
7044, Business and Professions Code). MOVING" - "- - TEL: - t^.. '�-108.=,�
(, as owner of the property, am:exclusively.contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and.Professions Code). I
T.
CONSTRUCTION'LENDING AGENCY SETT REQUIRED
YARD 'HWY - iOTAPREOP SETBACK-.FROM. __ WIDTH
I hereby affirm that there is a construction lending agency for FRONT ' 'I
the performance of the work-for which this-permit is issued P.L.
(Sec. 3097,.'Civ. C)• SIDE i +
P.L. - - - -
Lender's Name Ref. # "
o i
P.Cr Fee$- - _ -..:.._ Permit Fee:—
2 LAMA
Lender's-Address J
_.I'certify that 1 have read this.application and state that'.the . ..._ _v _. __... Issuance Fee-- " (! . - LDMA P/C#
a above information is correct. I agree to comply with all County Investigation Fee
g ordinances and State Jaws
relating,fq,building construction, _ _... . TotabFee•+* - LDW Perm::#
._ .
U and hereby authorize representatives of this County to enter ,
upon th bove-mentioned property for inspection purposes.-. t I
l -p Y 7 SEE REVERSE FOR EXPLANATORY LANGUAGE ;
�.
-`•. Signature of ApplicanhorAgent Date..••