HomeMy Public PortalAbout9861 LONGDEN AVE_Building__ s JERS'JrO0PENSATION DECLARATION
sure6y rr'tTrota havecertificate of consent to self PLiCATI FOR BUILDING PERMIT
insurte,�or a t'ertifitate of Workers'Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Ns. Company
F-1Certified copy is,her6by'furnished. FOR APPLICANT TO FILL IN BUILDING
''•.ADDRESS 7A 16 1 kZ9"d14N)
(� Certified copy is filed with the county building inspec- BUILDING VI /
�-S tion department. ADDRESS %L
L
/ !�
Date Applicant CITY ��i ZIP LOCALITY
NO.OF BLD
CERTIFICATE OF EXEMPTION FROM WORKERS' T NEAREST
".
COMPENSATION INSURANCE SIZE OF LOT 'S NOW ON LO ,.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 PARCEL
TEL. 'USE ZON�TNIV
I certify that in the performance of a work for whi h this OWNER �d NO. J Z permit isissued,I shall not employ n person in anner �p -{r AL
so as to become subject to the Wo Comp at' Laws. ADDRESS /`�" ���� ITIONS V
/ CITY C/L ✓qtr ZIP �.
Date Applican ARCHITECT O r TEL. E.7f- DISTRICT G UP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after makh this Certificate ofENGINEER CONST�NO. j d . Z V
Exemption, you should become subject to the Workers' i/
Compensation provisions of the Labor Code, you must forth- ADDRESS ,� /fiJ/'��, •��L���f " �� a
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. rONDO. fA
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC. x: CLASS NO. 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 P
Professions Code, and my license is in full force and effect. CITY CLASS BK S VALIDATION
SQ. FT NO.OF CHECK t
License Number Lic.Class SIZE Z//. STORIES (r FAMILIES ONE
DESCRIPt'LON OF WORK NEW �, VALUATION8 8 1.5 A
Contractor Date ADD $ # 0 0 0 0 2 3
I am exempt under Sec. �/J /1& 11111
-��
I o667.40
ALTER
$
3 3�d��i>>s Zi97�1sn� �.;
B.BP.C. for this reason Date: �+ f�� �' REPAIR ❑ '
EUSE XISTING o ° 6 6 7.4 0 3
ING BLDG. E;��lp%d�GrC DEMOL ❑'
Signature APPLICANT TEL. 7�d FIItIAL 0 1,21 -88
OWNER-BUILDER DECLARATION PRINT��jj� /, j�SZ N/O� lJ DATG%��
I hereby affirm that I am exempt from the Contractor's License ADDRESS �1 �'`V r ��� FIN
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT ,) By
BUILDING ti
1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and LOCALITY
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). MOVING TEL. n
I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS ( - 79575
tion 7044, Business and Professions Code). �.
REQUIRED TOTAL SETBACK s.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH o o 7 9 5.7 5 7
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. () 5 0_8 8
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
LDMA Ref. #
Lender's Address P.C.Fee$ Permit Fee
I certify that I have read this application and state that the Issuance Fee t/ o LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee r.
q o nances and St laws relating to building construction, Total Fee S �� 1 LDMA Perm.#
R n ereby outho z representatives of this County to enter
p e above- a ned property for inspectio%Fp osII� A SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig tura of Applicant or Agent Dafg