HomeMy Public PortalAbout9648 LONGDEN AVE_Building__ :Vl 61 IKE&COMPENSATION DECLARATION
f'hgreli}-'affiPm. thai ] have a:Certificate:of consent to'Serf q:P P:L CAT I O N: ��F`: R` BUILDING. PERM(T
insuce�'or a cer)jficate of Workers'Compensation Insurance, ' Os
`�Qr g c' tified cp i ereof'(Sec:3800,'-Lab. C.)' _COUNTY OF,LOS:ANGELES�t BUILDING AND SAFETY
�iP✓olricyf Ngo.�Y CompanyT/��� ,/
BUILDING
s.Certified copy is'hereby furnished. FOR APPLICANT-TO FILL INADDRESS
Certified co"py is filed with.the county building'irispec- BUILDING
tion'department.' ADDRESS L7
Date' �� : Ap'Plicant CITY ZIP• / LOCALITY
+CERTIFICATE OF EXEMPTION ROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION.INSURANCE „ 4 SIZE OF.LOT �`/.' ��d NOW ON LOT ! CROSS ST.
(Thiviiiction+need not be completed if the permit'is for'one. - -• •-• ,
ASSESSOR
hundred dollars($100)or less.) „
y TRACT S7U BLOCK LOT NO. MAE:BOOK ', :::k. :�-- PAGE E. _. _PARCEL
IL
I.certify rf
that in the,•peormance'of the work for which this.
OWNER _. ... TEL. ' US :ZONE,, OP..:
permit!''.isstied,1'shaft not employ any person in any manner,, .�Z SPECIAL =• O
so as'ta become stibject to the'Workers"Compensation Laws..( ADDRESS 3' CONDITIONS U
Date Applicant -s; CITY ;ZIP .. " O
NOTICE'TO`•APPLICANT: If, after.niakiitg thN Certificofe of ARCHITECT OR !TEL. DJSTRICT • GROUP, TYPE, .____ _FIRE PROCESSED BY. ,
ENGINEER /� NO ��v CONST. ZONE'
mp
Eiietion,• you'should become•subject to -the-Workers' LY
Compensation provisions-of the Labor.Code,.you•must forth-, ADDRESS 5C 0?' " y
with :comoly, with•'suchcprovisions or-.this permit shall be,; 7EL, STATISTICAL CLASSIFICATION APT. NDO. > Z
deemed revoked.., CONTRACTOR NO.. 043 �
'LICENSED CONTRACTORS DECLARATION:—. - LtC; --• CLASS IVO. DWELL UNITS '
1 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,/�dn��t��nYyyylicce�ense is m,full f_orce,and ct. CITY Ove CLASS BK " 'VALIDATION "-
:.i� 7'iY7�/t�� � # SIZEL� • STORIES
OFA HECK
DIES CONE
License.Number Lic.Class' J
ALIUATION
Coniractor� �'�/'�-/y Da}e DESCRIPTION OF WORK NEW •• =Q - ,
n,• ADD ❑ S'.
❑ I atn exempt under Sec. ALTER ❑
�.RAP.C. for this reason REPAIR. ❑ $ -
.�_:.... Date: USE OF DEMOL ❑ A-3 0 8,2.A .... .
EXISTING BLDG.
'Sign - APPLICANT TEL. _ o870,
` U
ature' FINAL
OWNER-BUILDER DECLARATION! (PRINT)' 4 NO. DATE-
hereby affirm that I am exempt from.the Contractor.'s License ADDRESS V •FIN o o
_ .. .. 2
Law for.the-following'reoson"(Section 7031.5, Business and Q �'a�i5.�..
'Professions-Code): . . _,w.-..... .. ... PRESENT
BUILDING B ' r
.E3..".1, o3 owner of the property, or my employees with ADDRESS '.i. + ; "`
wages as fheir•sole compensation,will do the work and ^ 3 a 3 A�
the structure is not intended or offered foisale(Section LOCALITY 4' +�•
"'7044, Business and Professions.Code). MOVING'
- - TEL." ;•; -�' ;`: `:, 1
c,
il�..
CONTRACTOR NO.
I,as owner•of the property, am exclusively contracting ::� :,: �' ;t}'�;•': .
with'licensed'contractors-to construct the project (Sec- ADDRESS"
tion 7044,.Business.and Professions Code).
REQUIRED TOTAL SETBACK FROM t•s `•'' ` t; s _ -
CONSTRUCTION'LENDING AGENCY ° SET BACK YARD' HW`!' PROP. LINE WIDTH
('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
P.L.. _ -- -•�. ;\ •t�'�, -
•Lender's Name -
�f LDMA Ref.:#
P.C..'Fee•$ V .� Permit•Fee O r ,.`. 1,a
Lender's.Address
r I.certify that I have read-this application and,state,that.the Issuance Fee..'• O� LDMA P/C Jr.
3 above information is correct. I agree to comply with all County Investigation Fee '
ordinances and State laws relating to building construction, - Total Fee
016712- LDMA Perm. #
and hereby authorize rep resentatives'of this County I enter
i;'•• upon the above-menti o rty for-inspection purposes. -
' SEE REVERSE FOR EXPLANATORY LANGUAGE.
-Signatur of or Agent Date