HomeMy Public PortalAbout9628 LONGDEN AVE_Building__ • � -WORKERS'COMPENSATION DECLARATION
=' 0�{,4�i>'1'�y c;i/m that'I have 6 certificate of consent to self pp
insu.i or=rtifj�ate of Workers'.Compensation Insurance, A;l:•:R 4 L I C,AT�.O IV F�O R BUILDING P E RSA 11' �.�,
or a certified copy thereof(Sec. 3800, Lob. C.) :`,�000NW,0E-LOS ANGELES- BUILDING AND SAFETY
PoIicy Nr+o _Compony_95M �1 �77r( .,r,.
10
Certified copy is hereby furnished. FO APPLICANT TO FILL tN ADDRESS �Q y
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS' Y
` Lh3
Date Applicant CITY �irl ZIP �I7�V LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' ' , NO.OF BLDGS. NEAREST (/ -
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. i
(This section need not be completed if the permit is for oneASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK I Ar PARCEL
TEL lJ�l
I certify that`in the performance of the work for which this OWNER �i" ,'^ . NO. USE NE OP
permit is issued, I shall not employ any person in any manner ADDRESS ! + tl0.. /J t/rf CONDITIONS ,
PE IAL
so•a��s''to become subject to the Workers'
/C Compensation Laws.
V
Datg�/ X 27 99 Applicant�ff r PjFG,=—J7`fJc CIT` v e` �a� ZIP 0 Q
NOTICE TO APPLICANT: .1 after making' this Certificate of ARCHITECT OR r, TEL. /j DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you.should become subject to the Workers' ENGINEER /�' 4 NO.-W5 _py CONST Z�E V
Compensation provisions of the Labor Code,'you must forth- ADDRESS a (!/�J'1 a
with comply with such provisions or this-permit shall be . TEL.S•/yr STATISTICAL CLASSIFICATION APT. ONDO.
deemed revoked. CONTRACTOR / /• Q NO. -ig +
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 7 V D O L P E NO.
(commencing with Section 7000)of.Division 3 of the Business and LIC SEWER MAP ;2 9 5 7.9 A
Professions Code,and my license is in full force and effect. CITY Oft :,, 1/d 0-C CLASS BK. PG. VALIDATION
SQ.FT. NO.OF NO.OF CHECK o 0 0 0 3
License Number Lic:Class SIZE ' STORIES FAMILIES ONE
AJ I I— NEW VALUATION ( 0 6 1 0, 10
DESCRIPTION OF WORK ;
Contractor Date '
E]I am exempt under Sec.
.3. QS l�L�(��.3 �� ADD a o e 6.1 Q 1 0
• ALTER 1
B.&P.C. for this reason u . oc: R LU At& � O�/) �5 1 11 "'8 8
REPAIR ( vVV lllfff
Date: USE OF DEMOL
EXISTING BLDG.
APPLICANT TEL.
Signature FINAL
OWNER-BUILDER DECLARATION PRINT NO. DATE
I hereby affirm-that I am exempt from.the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
Professions Code): PRESENT B
BUILDING
I, as owner of the property, or my employees with ADDRESS s �;;." ; 1 �0 2'&4 A
wages as their.sole compensation,will do the work and 1' ,t .N-,:•
the structure is not intended or offered for sale(Section LOCALITY ,� ''''- -�• } _ o 0 0 0 0 1
7044, Business and Professions Code). MOVING TEL. ' i1 ,i.
E3I,as owner of the property,am exclusively contracting CONTRACTOR NO. /Q o 1 '(,.0 8 4 0.7 5
with licensed contractors to construct the project (Sec- , ADDRESS o 0 8 4 Q 7 5 c�i
tion 7044, Business and Professions Code).
REQUIRED TOTAL ROP. LI FROM
_ q 07,27--88
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH � � 1/' 1
I hereby affirm that there is a construction lending agency for FRONT 1 0 2
the performance of the work for which this permit is issued P.L. # '
(Sec. 3097,Civ. C.). SIDE '
P.L. -0-!--- 9S62
D Lender's Name LDMA Ref. M \70 0 0 9 5(�
Lender's Address P.C.Fee Permit Fee S
I cerci that I have read this a lication and state that the t� t� 7.2
7.-88
fY pp �J Issuance Fee �►✓ LDMi4 P/C N ;
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws rlatin to building construction, g 0 37 ��• t
and hereby authori reWls:e�ni of this County to enterTotal Fee , LDMA perm.q
upo a-m dofor Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ature o pplicant or Agent'` ate / r
i