HomeMy Public PortalAbout9515 LIVE OAK AVE_Building__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have certificate 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 \
❑.
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN AD
DING RESS
Certified copy is filed with the county building inspec- BUILDING +
'tion department. ADDRESS Ve_ �by, NO(!,
w% .+ _
Date,fl t�a ) Applicant 4 CITY e� `E ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WO KERS' NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE I SIZE OF LOT 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
�(� TEL.,-�q q USE ZO E P
I certifythat in the performance of the work for which this OWNER t 1 1 ( 6 NO.�O�— `Z�� O. �.
p SPECIAL
permit is issued, I shall not employ any person in any manner (� C� e
so as to become subject to the.Workers'Compensation Laws. ADDRESS 1 ,J '^\fie 1_.1x11 Vl� ' 117, CONDITIONS V
CITY ZIP cc
Date Applicant 0
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP I TYPE FIRE .. PROC SED BY
11—
ENGINEER NO / CONST. ZONE W
Exemption, you should become subject to the Workers' g' vX �_?� /
Compensation provisions of the Labor Code, you must forth- ADDRESS J vUU J V ®"
with comply with such provisions or.this permit shall beT i TEL. �i l STATISTICAL CLASSIFICATION APT. IC DO. Z
deemed revoked. CONTRACTOR J,.w.C NO J ft
'' ''
LICENSED CONTRACTORS DECLARATION LIC. q CLASS NO. DWELL. UNITS
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �\ NO. `J
(commencing with Section 7000)of Division 3 of the Business and LIC. /� SEWER MAP
Professions Code, and my license is in full force and effect. CITY �.� JU� CLASS l '� BK PGVALIDATION
?Inb��
SQ. FT. NO.STORIES
IE FA OF CHECK.
License Number�� Lic.Class �— SIZE STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK `(Irani NEW f�
Contractor Zk Date ADD $ �^ +v' 06 ;92069A
r
El 1 am exempt �1
under Sec. ALTER # o 0 0 ® o 1
B.&P.C. for this reason REPAIR
$ Imm5925
Date: USE OF DEMOL Q
EXISTING BLDG. 5 9 2 5 v
Signature FINAL /
APPLICANT TEL. ✓ 0 0 0
/11
OWNER-BUILDER DECLARATION (PRINT) NO. DATE I. l/
I hereby affirm that I am exempt from the Contractor's License 0 2.0,-8,5
Law for the following reason (Section 7031.5, Business and ADDRESS FINAI
Professions Code): PRESENT By
BUILDING f�
I, as owner of the property, or my employees with ADDRESS �f
wages as their sole compensation,will do the work and L'
the structure is not intended or offered for sale(Section LOCALITY '
7044, Business and Professions Code). MOVING TEL.
I, 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).
REQUIRED- YARD HWY NOTAL SETBACK FROM .
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE 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
m
P.L.
o Lender's Name
LDMA Ref. #
Lender's Address P:C. fee$ Permit Fee
> /'
t I certify that I have read this application and state that the Issuance Fee V LDMA P/C#- -
a above information is correct. I agree to comply with all County Investigation Fee e
m ordinances and State laws relating to building construction, _. .. Total Fee �� `� LDMA Perm. #
u and hereby authorize representatives of this County to enter
upon thb abo e-mentionMroperty for inspection purposes.
2 � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur 'of Applicant or Agent Date