HomeMy Public PortalAbout9531 LONGDEN AVE_Building__ " WORKERS'COMPENSATION DECLARATION
* t he,ek�4'affcertific i hff�`W Workers'
rs'Come of consent to'self APPLICATION FOR BUILDING PERMIT
• insure, or a certifica'1•e of Workers'Compensation Insurance,
O"i certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company •
❑ copy y FOR APPLICANT TO FILL IN BUILDING
Certified co is hereby furnished. ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS L�
Date Applicant CITY - r— ZIP21 7A LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. Qrj
(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. USE ZONE MAP
I certify that in the performance of the work for which this OWNER NO.'� 'a NO.
permit is issued, I shall not employ any person in any manner o ' SPECIAL a
so as to become subject to the Workers'Compensation Laws. ADDRESS = CONDITIONS V
Date Applicant CITY L9 '— ZIP cf178 a a
NOTICE TO APPLICANT: If, after making*this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
ENGINEER NO. CONST. ZONE (--
Exemption, you should become subject to the Workers' !!�� z V
Compensation provisions of the-Labor Code, you must forth- ADDRESS f(J9 3 W.
with comply with such provisions or this permit shall be
deemed revoked. TEL. STATISTICAL CLAS IFI. ATION APT. CONDO.
CONTRACTOR � NO. � Z
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 and LIC.
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION
$Q. FT. /n� NO.OF NO.OF CHECK
License Number Lic.Class SIZE `'GSTORIES FAMILIES ONE
VAL TION
Contractor Date DESCRIPTION OF WORK. NEW C] ;__�
ADD
I am exempt under Sec. Ea3cl Am,I Q ALTER EF] pill
B.BP.C. for this reason REPAIR ❑ $ I�3��d 0d c'� 1 A
DUSE OF
Dote: L
EXISTING BLDG. DEMO ❑
Signature APPLICANT TEL. FINAL ° 385.C5
OWNER-BUILDER DECLARATION PRINT Z NO. DA : ° " J 6 r;
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS � Losuunc �/ — F1 i 1 �,!Z,—8 8 �4
Professions Code): BY
e
J��j BUILDING AC�.ACCTIr I, as owner of the property, or my employees with ADDRESS p
wages as their sole compensation,will do the work and LOCALITY 3307 ''i
the structure is not Intended or offered for sale(Section n
7044, Business and Professions Code). MOVING TEL.
r �S 9yL i i Ti E ��
❑ CONTRACTOR NO. T (!
I,as owner of the property, am exclusively contracting � �.
with licensed contractors to construct the project (Sec- t p TOTAL '
tion 7044, Business and Professions Code). ADDRESS y { � �f"�J7�
REQUIRED TOTAL SETBACK t•HE4f\
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 1
CHANGE
t
I hereby affirm that there is a construction lending agency for FRONT o
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE p. �}. t;
P.L. O,
Lender's Name `_ /1 r -� t-�' �jpl'�fI-C►C��11
i P.C.Fee$
3 a`�•/.,6J Permit Fee t LD Rel! y� t{i3 i � 4q {
Lender's Address � //� 4 QO1 1 t ;'
I certify that I have read this application and state that the T 4 7! I Issuance Fee ) 0r MD P/C a Poo p
above information is correct. I agreg to comply with all County Investigation Fee �• U7
t ordinances and State laws relatg'to building construction, Total Fee J O ' DMA Perm.N
and hereby orize represent tives of this County to enter
S upon th ve-men'oned propPerty for inspection purposes. 3 Z.
I
/ y
g� SEE REVER E FOR EXPLANATORY LANA
(..rl cu e3 -, Cy p
Signature of Applicant Age Date 7� 1.-,t '0 I 7 CJ �
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