HomeMy Public PortalAbout6463 LOMA AVE_Building__ WORKERS' COMPENSATIONDECLARATION
I'hereby affirm that I have'a certificate of consent to self A L I C �{ q"I F U I L I PERMIT
insure; or a ceriific'ate of Workers' Compensation insurance
or a certified copy,thereof (Sec. 3800, Lob.
C.,)�G a
Policy'No. JT/7✓z- ` Ch C�
_ UNTY'OF LOS ANGELES '�BUILDING AND SAFETY'
Pony ;
❑ Certified copy is hereby furnished.. t . BUILDING'
FOR_APPLICANT TOFILLIN
Certified copy is filed'with the'•county building'rnspec BUILDING ly
' ',;' ti ) 'AY", s •'
r /I
tion department) ADDRESS 'f - ; �
��`,,r]� t.•, _
.: Date '• /~/D.. Applicant 4 44. •`���"/V.V - - CITY s.�l� �! <f . t/;•-'.ZIP;.•:. i/ LOCALITY .. .
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CERTIFICATE OF EXEMPTION FROM WORKERS Y Y x " NO:`O F'eLDGS.` NEAREST `
COMPENSATION INSURANCE SIZE OF LOT - . NOW ON LOT CROSS ST.'
(This`s`eciion need not be completed if the permit is for one
k' ASSESSOR
hundred,dollcim($100)or less.)' TRACT BLOCK TL OT NO. MAP BOOK PAGE,.. PARCEL
% .. • TEL.
^ MAP
�41V CEs M .� NO., USE ZONE 'MAP-
1,certify that in'the performance of the work for which this OWNER NO. 1p'
permit is issued';i shall not employ'any'person inany manner -' / / /�' SPECIAL
so'as to become subject to the Workers'Compensdtiontaws. ADDRESS ,(d T • L rJ 1� r'/ CONDITIONS 0t y
n�,,, Q / U
CITY �i)'61. ZIP `-7 { 7 '
Date Applicant D_
` ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after,making this Certificate of DIST RI T GROUP TYPE ONS, FIRE 3CESISED Y tom. "
Exemption, you should become subject to the Workers
.ENGINEER NO.
: Compensation-provisions of the Labor.Code,,you must forth ADDRESS lJ��t� R� W
with comply,with such provisions or,,this permit shall be LL
p TEL STATISTICAL CLASSIFICATION APT. CONDO.
deerned;r LICENSED CONT CONTRACTOR J� S�oO�/�i1G 0 {,AS/�NO. / 1�`3/g�
CONTRACTORS DECLARATION;. LIC, CLASS NO. DWELL.-UNITS'
II••� ) ..
I hereby off irrri that am licensed under provisions of Chapter 9. ADDRESS IS VII• Irtr� N'l;NO.
(gommehcing with Section 7000 of Division 3 of the Business and SEWER MAP
Professions Code, and my license'is•iri-full foice and effect. CITY CLASS BK• PG. �' VALIDATION'
/J SQ. FT. INC. OF NO. OF j CHECK
License Nurriber`- r5 23, Lic.Class vs ®�" SIZE On STORIES FAMILIES .¢ ONE '
�L � I�w t1 'o' / r . VALUATION
' •DESCRIPTION OF WORK •S T�1 P P/�►-S�Al,L• NEW ❑ `'f) �p
Contractor - Date IL
am'exempt under'Sec. x2 "CDS ��7 fV'� 3o'I Fecr ADD
_
ALTER ❑
B.BP,C, for this reason 25' CA-9 �•/>��.r•�1` W00DL N F C &IR $
-
Date:
EXISTING BLDG.USE OF "rG C.S , DEMOL. ❑
TEL
Signature OWNER-BUILD R L AT APPLICANT �' O NO. ) 3) FINAL
PRINT
ARATION , DATE
I.hereby affirm thot I am exempt from the Contractors License t'-
Low for the following,.reason (Section 7031.5, Business and ADDRESS '7 I z? 7, 'W• l eAf1 DQ FINAL
Professions Code): R By - -�-f QE_^;i
BUILDING' r
I, as owner of the property, or my employees with ADDRESS Hua y a
❑ wages.as their sole compensation,will do the work'and
the structure is not intended or offered for sale(Section' LOCALITY - LIQ - i
7044, Business and Professions•Code) MOVING TEL. ' • �
CONTRACTOR NO, i ITEM,`)
i
1; •:i
I, as owner of the property, am exclusively contracting .: .; .with licensed contractors to construct the project (Sec-, ADDRESS L "" 11 �`� e
tiori7044, Business and Professions Code): -
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK '.YARD HWY PROP. LINE WIDTH ,
1.40.•}a
I hereby affirm that there is a construction lending agency for FRONT
the performance of the.work-.for which this permit is issued P. z:[frfCiat „inti
(Sec. 3097, Civ. C.j. SIDE '
PA.-
'Lender's Name - r( .
m C. Fee$ Permif.Fee i
.ISI
P.
.. nn
Lender's Address /� '�U nth a
LDMA Ref. # I Elf �I ` i
o I certify,ihat I have.,read this application and state that the i,' issuance Fee. �J. �. LD
P/C#
® -
above information is correct. I agree to comply with all County Investigation Fee �I,
o ordinances and State laws relating to building.construction, Total Fee. �_l1 ^_- (! LDMA Perm.'#
o and hereby authoriz' 'representatives of this County to enter'
upon the-Glocive m n oned property for inspection purposes.
`.. . - ..
' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Appl' nt or Agent .- 'Date �-