HomeMy Public PortalAbout8854 LONGDEN AVE_Building__ y)RKEi'2S COMPENSATION DECLARATION
�. =I hereby affirm that I.have a certificate of consent to,self O O O D -Dom
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insure;or d certificate of Workers Compensation Insurance, Q PIP d D C�ATO OO G� ��.G3f d DD �[�9 p E mc) 0�.
'or`a certified copy thereof'(Sec:.3800 lab`. C:)
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COUNTY OF, AWLOS-ANGELES BUILDING, S`�.FETY _ ?
Policy No to Company ,_.,.. .
e , ,
Certified copy is hereby,furnished t„ FOR APPLICANT TO.FILLIN`. ,
J
BUILDING G,�w GEr
Ceriified'cop is filed vv+th the`countybu+lding'mspec- BUILDING. *�
' a tion:d'eparimenT,. . ADDRESS �V G.. �(/�✓ (IG Al
ADDRESS `
Date.``.; - APPlicanT, . Y c :.; CITY / ��� CST' ZIP S77 � LOCALITY- 1t C!'
x d%N �..... _ r...-. __- - /-`<, :NO:-OF BLDGS. .- ' NEAREST.. w
CERTIFICATE OF EXEMPTION FROM WORKERS "7�y ! OS
SIZE OF LOT I NOW ON LOT CROSS ST_.a
-' ' 'COMPENSATION'INSURANCE t�x�. _
(This'sect+on need not be completed=if•the permit'is?for,one - - ,f"Ifo - T ,�/ ASSESSOR
- ¢tA "1 t? Oi
ASSE /.�
hundred dollars'.($100)or.less ) : TRACT BLOC T (9 PA
PARCEL
T K LO NO. MAP BOOK
OWNER{.l �Fi^N.�,J / Nb:'eC�J-tiS�IG'7 ls+�. V
:1,.certify that in the performance of the work'for,which this ,,/ �P Y
permit;is issued,I shall.'not employ any personpin ony'rmanner LBa/• d�/1�_ y� SPECIAL t ; - - - �.
USE NE
i
,:
- ADDRESS ! ° + 01
so as'to become sublect:to the Wa ers Compensation Laws. O
<Jl[
CITY-
A" . .E . C/ ' ZIP
CONDITI NS
Date: ppl+can ARCHITECT O _ __. TEL.
d UP E , _ FIRE _ P SED.BY .,...+
NOTI E'`T ;APPLICANT :If; d r ma mg thrr Certificate:of ENGINEER `G a�� Co6•� NO. x-97- PV•20 1-
Exerription you should•`.b"e me subject to"the Workers' ,- DISTR
ICT GRO TYP,
J CONST Z E
Compensation;provisions of The Labor:Code, you musttforth ADDRESS / �� _°� �✓•`-"�••
��7►
with comply-with`such".provisions or;?this,permit shall,be T
TEL. STATISTICAL CLASSIFICA ION '.APL C DO
deemed,revoked t;,; c r `.' CONTRACTOR /b��®A� }S� o2FJ-S/6 ,
NO.
LICENSED CONTRACTORS DECLARATION'. a:.t - •• LlC - - CLASS NO DWELL. UNITS
I hereby pffiim,that I.am licensed under provisions'of Chapter 9 ADDRESS NO:
E,
(comm@ncmg,with Section 7000)of Drv+sion 3 of;the'Busmess:and ! LIC. _
r SEW R MAP ,
Profess ons:Code, and my license is in full"force,.and effect. CITY ��'� �'d
-C -7, CLASS r --
VALI O
SQ. NO. OF-
NO.OF CHECK
BK. PG.
License.Number L+c.Class
SIZ STORIES' FAMILIES �M -ONE I f wt ` ' y DAT .�S Jt, f
„ , � VALUATION --
Contractor ta. Date
DESCRIPTION OF WORK "'�G^ -NEW--
Co
NEW a $ , �' "iD��
'a.• _ ADD 0 U ,
I am exempt.under Sec ALTE47 R
B.BP C. for this reason REPAIR
USE OF
O $
'Date
EXISTING BLDG. DEM O
;..; APPLICANT' TEL.: # '°
F•�
Sign`oture "` PRINT V/E(�L A/ iy.S/ NO:a�7=$�/6.7, FINAL 1 '
45
OWNER-BUILDER DECLARATION- I _ _ DATE>
6h ereby,affirmxthat I am exempt from the Contractor s:License ' �•� /�•-LUQ v fi Te* y." c
Law..for the followiod.reason'+(Section 7031.5;.Busines's and ADDRESS FIN' I 'O 1 9 0 5 0
_ -
`Professions'Code)` "' PRESENT - BY u !
BUILDING ' ° 1 9 Q 0 v ,
- s °
ly as owner of the property, or my ernployees'with ADDRESS
wages as their sole com,'pensation,wilhcJo the work and. r; t
the structure is not intended or offered for said(Sectionje
LOCALITY - 0 Q 'J 0-•$(�
7044 Business'and Professions Code). MOVING ' TEL
a
CONTRACTOR: NO.• 4 4
_Q I, as owner of the property, am exclusively contracting, ;_ _ _
with-licensed-c htractbri to`construct the'project (Sec- ADDRESS a
tion'7044, Business and Professions Code):'
._REQUIRED. TOTAL SETBACK'FROM:1_. I T.
CONSTRUCTION-LENDING AGENCY:-- "' 'SET BACK YARD HWY'" PROP:LINE WIDTH''. a s V t )
I hereby affirm that there is a construction lending agency for FRONT -
- -
the performance of the viork;for which This permit is issued P:Lr
(Sec. 3097;'Civ. C.): SIDE
M
m P.L. _ - - -- -
Lender's Namei.
LDMA Ref. #• ° '
m
Lender's Address P.C:Fee$ PermirFe
\ - i. }
L'.certif.y that.l_have_reiad.this application and.state-that the Issuance Fee— •• i '-(/- { LDMA P%C
above.informotion incorrect. I agree to complywith all County Investigation Fee
ordinance's and State laws relating to.building construction, _ _.,_____ . _- Total•Fee- V LDMA`Perm-#• U - - r
v and hereby authorize representativesof this County to enter
'm up n the above-mentioned property fof inspection purposes.
r
SEE REVERSE FOR EXPLANATORY LANGUAGE
Anature of Applicant,orAgent--:_. _::_ ..Date