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HomeMy Public PortalAbout9548 LIVE OAK AVE_Building__ WORKERS' COMPENSATION DECLARATION insure bor affcertif calte of Workers' Comtpensation eInsuran of APPLICATION FO aRrill 'I L l N G PERMIT , or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES `~ BUILDING AND SAFETY Policy No. ' Company BUILDING' Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS Ll( g- CITY L ZIP LOCALITY C. , Date Applicant NO.,OF BLDG5. NEAREST M CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. M COMPENSATION INSURANCE ASSESSOR �y / (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK �� O PAGE �lJ�c PARCEL lice hundred dollars ($100)or less..) TEL. OWNER' � � { J�z NO. �7 USE ZONE MAP / •� ��/ M I certify that in the performance of the work for which this NO. / rp cy T SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS /� �v� ©�� cam! CONDITIONS so as to become subject to the Workers'Compensation Laws. 0 n� cl E �.- e( zip U Date Applicant ARCHITECT OR TEL. DISTRICT GROUP ITYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZE V Exemption, you should become subject, to the Workers' Qt� W J Compensation provisions of the Labor Code, you must forth- ADDRESS J y cJ N ' rF- with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z O \ deemed revoked. CONTRACTOR L��' y NO. — ~' LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. / DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. Q-11and Professions Code,and my license is in full force and effect. CITY CLASS BK PG 7 VALIDATION � t SQ. FT.g• NO. OF NO. OF / CHECK License Number Lic. Class SIZE �7(�Q STORIES FAMILIES / ONE VALUATION Contractor Date DESCRIPTION OF WORK 6D "L•J'/1/ NEW ❑. _ D ' DOM - ADD J ❑I am exempt under Sec. ALTER B.&P.C. for this reason / v It L.D S O `/►� REPAIR ❑ Date: USE OF �� jQ. - EXISTING BLDG. DEMOL '_';E1L' 'e p.. APPLICANT TEL. Signature FINAL =f -t ='! ' (PRINT) NO. a OWNER-BUILDER DECLARATION DATE s"; I hereby affirm that I am exempt from the Contractor's License }'t') `'3 _ Law for the following reason (Section 7031.5, Business and ADDRESS FINALProfessions Code): PRESENT By BUILDING 1, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and 9 P p x yt Y a ( LOCALITY €1. the structure is not intended or offered for sale Section / - 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner.of the property, am exclusively contracting CONTRACTOR NO. �•�"t:.',i,;'with licensed contractors to constructthe project (Sec- ADDRESS tion 7044, Business and Professions Code.) REQUIRED RD HWY TOTAL SETBACK FROM EXIST. �/J��7' CONSTRUCTION LENDING AGENCY SET BACK YARD PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT theperformance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name /'/ m P.C. Fee$ (O'7 , Permit Fee7;116 /4 em LDMA Ref. # Lender's Address o I certify that I have read this application and state that the =7 3 �� Issuance Fee c7? LDMA P/C# 8 above information is c rr ct. I agree to comply with all County Investiga ion Fee R tau- and State ws,relating to building construction, Total Fee / s✓ LDMA Perm. # a orize r re ent Ives of this County to enter o�v mention d rop tfor inspection purposes. / �` SEE REVERSE FOR EXPLANATORY LANGUAGE Signatre of pylic nt or Agent Date