HomeMy Public PortalAbout6015 MUSCATEL AVE_Building__ 1
WORKERS'COMPENSATION DECLARATION Z141
su reby affirm that I have r certificate of c.do `e s ranee, L I CAT ISO N FOR BUILDING PERMIT �
insure, or a certificate of Workers'Compensation Insurance, '� O -
ck 'or a c rt• ied co thereof.(Sec. 3800, Lab. C.)
/CIc ` Cipany ��� ,s j COUNTY OF LOS ANGELES BUILDING AND SAFETY
' 'I Certified copyishereby furnished. ^ F FOR APPLICANT TO FILL IN BUILDING
RESS e,
ADD
Certified copy is filed with the county building inspec- BUILDING /J•_
tion department. ADDRESS L• $ LOCALITY
_-ZNEAREST
(Date Applicant CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT 100, NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars($100)or.less.) TRACT BLOCK LO7 NO. NO. a
` t SPECIAL
1 certify that in the performance of the work for which this OWNER dt NO. CONDITIONS /,, 7 J CL
permit is issued,I shall not employ any person in any manner ISTR� .GROUP TYPE FIRE P ED BY ADDRESS C
CONST. ZONE 01
(/. r
so as to become subject to the Workers'Compensation Laws. � i of.
/ 6�
Date Applicant CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO.
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT O TEL. tj
CLASS NO. DWELL. UNITS
'Exemption, you should become subject to the Workers' ENGINEER O. 9L
Compensation provisions of the Labor Code, you must forth- ADDRESS a SEWER MAP
with comply with such provisions or this permit shall be
deemed revoked. CONTRALTO 7 p, 3 BK. PG,/d / VALIDATION
LICENSED CONTRACTORS DECLARATION � J ,q LIC.
I hereby affirm'that I am licensed under provisions of Chapter'? ADDRE Q[ !✓ a t ✓ NO VALUATION
;(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 f $ U O Boo.
to DESCRIPTION OF WORK NEW
,- SQ.FT f IN .OF NO.OF CHECK
-License Number •7.- Lic.Class• A SIZE .GV STORIES— FAMILIES ONE
-s .� $
❑
ADD
I am exempt under Sec. � ❑
ALTER FINAL
B.BP.C. for this reason REPAIR ❑ DATE [. je o� F C6 8 3 A
Date: USE OF AL
1 it o a a o o }
EXISTING BLDG. DEMOBy a
L ❑ �- f
By a"-o= .�� .
Signature APPLICANT L. 6 r [ 0 -'9 6,
OWNER-BUILDER DECLARATION PRINT' O. 7g
I hereby affirm that I am exempt from the Contractor's License ESS eJs� " 00 ° C.
ADDR
Law for the following reason (Section 7031.5, Business and
'Professions Code): PRESENT
BUILDING G+
I, as owner of the property, or my employees with ADDRESS
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,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIREDTOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY' SET BACK YARD HW? PROP.LINE WIDTH
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.
tSec. 3097, Civ. C.). SIPE
�. s � 7, �/J J/�• P.L.
A
Lender's Name +
Lender's Address P.C. Fee$ Permit Fee .o�
r I certify that I have•read this application and state that the Issuance Fee J
above information is correct. I agree to comply with.all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee �j
and hereby authorize re pr tatives of this County to enter
upon h bove-me i operty for inspection purpos S.
01
�' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Applicant or Agent Data ®s