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HomeMy Public PortalAbout9666 LIVE OAK AVE_Building__ WORKERS'COMPENSATION DECLARATION insure,oraafcertif cafirm tharte of Workers' Comtpensat on eInsuran ent to lf APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. 1039547 company State Compensation COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is hereby furnished. Insurance Fund FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building i pec- BUILDING © VC, Oq tion department. ADDRESS 9666 E. Liveoak Ave. Date 6-6-89 Applicant CITY Temple City zip 91780 LOCALITY / CERTIFICATE OF EXEMPTION F M W09 ERS' NO. OF BLDGS. NEAREST COMPENSATION INS MW 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 I PARCEL OWNER Bob Loeffler (818)-TELNO. 285-5029 USE ZONE MAP / . _ I certify that in the performance of the work for which this NO. permit is issued, I shall not employ any person in any manner9666 E. L1V20ak Ave. �— SPECIAL1 so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS O CITY Temple City Zip 91780 0, Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRIC GROUP TYPE "� FIRE PROCESSED BY � Exemption, you should become subject to the Workers' ENGINEER NO. CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS ! /P t' W with comply with such provisions or this permit shall be p_k deemed revoked. TE STATISTICAL CLASSIFICATION APT. CONDO. N CONTRACTOR United Roofing Co.Nd13-223-408 ;. Z LICENSED CONTRACTORS DECLARATION LIC CLASS NO. (DWEL:UNITS _.lI hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1821 Daly St. NO, 137650 (commencing with Section 7000)of Division 3 of the Business andLIC SEWER MAP Professions Code, and my license is in full force and effect. CITY LOS Angeles, CA. 90031 CLASS C-39BK / VALIDATION SQ. FT. NO.OF NO. OF CHECK License Numb r 117.650 Lic.Class C-39 SIZE STORIES FAMILIES ONE VALUATION Contractor 6-6-89 DESCRIPTION OF WORK Remove existing ❑ate NEW roof. Install 2 layers 40#felt ADD ❑ $ 6500.00 I am ex pt unr Sec. 1:1 , unaerlayment. InstaTImission ALTER E] B.BP.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL ❑ EXISTING BLDG. required. Signature APPLICANT TEJ,. FINAL-e-7o OWNER-BUILDER DECLARATION PRINT United RoofingCo. NQ1.13-223-408 :.DATE G I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS 1821 Daly St. , Los Angeles 90031 _ FI /r Professions Code): PRESENT1 ❑ BUILDING I, as owner of the property, or my employees with ADDRESS a wages as their sole compensation,will do the work and ACCT.T the structure is not intended or offered for sale(Section LOCALITY ' 3 L 7044, Business and Professions Code). MOVING TEL. �c CIL ,1 �� 'o'�r ❑ ICONTRACTOR NO. , as owner of the property, am exclusively contracting % 1 ITEMS a... with licensed contractors to construct the project (Sec- ADDRESS � tion 7044, Business and Professions Code). TOTALS��! '�C�Su:� o REQUIRED TOTAL SETBACK Y CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH CHECK 96.75 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. CMNGE .. ... .00 (Sec. 3097, Civ. C.). SIDE P.L r Lender's Name 0000-0001 p� m 89 P.C. Fee$ Permit Fee 86,25 LDMA Ref. # .p0, uli Al111�40 Lender's Address ' 3 10.50 LDMA P/C# g I certify that I have read this application and state that the, Issuance Fee o above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws reI tin to building construction, Total Fee $ 96. 75 LDMA Perm. #' and hereby authoriz represe ves of this County to enter m upon the ove- toned perty for inspection purposes. m o 6-6-89 SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of icant or Agent Date