HomeMy Public PortalAbout9650 LONGDEN AVE_Building__ a►, ,`jVORRERS'COMPENSATION DECLARATION
.hereby affirm that I have a c Rrtificate of consent to Self APPLICATION FOR BUILDING PERMIT
y insurer,•vr a certificate of Workers'Compensation Insurance,
+�#r rt'fied c eof(Sec. 3800, Lab. C.)
0-, O COUNTY OF LOS ANGELES BUILDING AND SAFETY
o icy o. Company �J BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 6 S�
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ��J� ADDRESS /
Date A f Applicant�� `r CITY ZIP LOCALITY zm
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT O CROSS ST.
PARCEL
(This section need not be completed if the permit is for one BLOCK LOT NO. ASSESSOR
hundred dollars($100)or less.) TRACT MAP BOOK
S7C7 PAGETEL
OWNER C�.�1 NO 7S �3 USE ZONE MAP
I certify that in the performance of the work for which this NO. 2 }
permit is issued, I shall not employ any person in any manner . SPECIAL IL
so as to become subject to the Workers'Compensation Laws. ADDRESS V
Date Applicant CITYdeC2 r'r'J ZIP Ot:
ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE U
Exemption, you should become subject to the Workers' �j x -�j
Compensation provisions of the Labor Code, you must forth- ADDRESS S VE ✓i �v 4` y
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. JONDO. Z
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. G 94—DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC, SEWER MAP
Professions Code, and my license is in full force an ct. CITY CLASS BK PG VALIDATION
(�� SQ. NO.OF NO.OF CHECK
License Number! ly Lic.Class SIZE 9U STORIES FAMI ONE
VALUATION
DESCRIPTION OF WORK i NEW
Contract��v Date ADD ❑ $
FI I am exempt under Sec.
p ALTER ❑ pill AR308.5A
B.BP.C. for this reason USE OF REPAIR ❑ $
# aaaa23
Date: EXISTING BLDG. DEMOL ❑
FINAL
Signature
APPLICANT TEL. 1 - 87(120
OWNER-BUILDER DECLARATION PRINT) NO. DATL �"
I hereby affirm that I am exempt from the Contractor's License o o 8 7 Q 2 C 5
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
Professions Code): PRESENT BY 0,07-85
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS a 3 Q a b A
wages as their sole compensation,will do the work and '
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. I 1.C 3 4.2 5
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. _
with licensed contractors to construct the project (Sec- ADDRESS o 1.C 3 IL 2 5 6
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY ED TOTAPROP.SETBLIINECK FR M WIDTH O,O 7 $5
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE f
P.L.
Lender's Name TDMA Ref. # '
3 P.C.Fee$ Permit Fee 1,d2
Lender's Address /' '
r I certify that I have read this application and state that the Issuance Fee 16,S0 LDM
GA P/C#
r above information is correct. I agree to comply with all County Investigation Fee Al
ordinances and State lacing to building construction, Total Fee UcJ 2� LDMA Perm. #
and hereby auth epr entatives of this County to enter
0 - nti d pro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatur p icant or t p e ��--