HomeMy Public PortalAbout6112 MUSCATEL AVE_Building__ WORKERS'COMPENSATION DECLARATIOI rd'`�•�� ` �' 1, "
I hereby affirm that I hoveoa cerflf.-ate of bonser� self �j� D F
insure, or a certificate of Workers'Compensation Insurance, 11-3-1 11 �T ON ® I L D I N G PERMIT
or a certified copy thereof (Sec. 38 L b. C.
COUNTY OF LOS ANGELES ' { BUILDING AND SAFETY
Policy R1o.R513 2f D_Company '
-Certified copy-is-hereby furnished: ' FOR APPLICANT TO FILL IN BUILDING I Z C
ADDRESS
Certified'copy is filed with the county building Inspec- BUILDING f^I I D �•
tion department. ADDRESS, tD I
� / C/
Date Applicant CITYft- C�J
ZIP �' LOCALITY �.
CERTIFICATE OF EXEMPTION FROM WORKERS' A' NO.OF BLDGS. NEAREST -•
COMPENSATION INSURANCE' SIZE OF LOT IV A NOW ON LOT A r CROSS ST. C ( b
(This section need not be completed if the permit is for'one IV .� A O ASSESSOR, /{ N/A 4 ;
hundred.dollars ($100)or less.) TRACT BLOCK LOT NO. Mqp BOOK fl PAGE -1 PARCEL /1
TEL.7�/„_ 7,{ USENIA -ZONE MAP
I certify that in the performance of the work for which this OWNER NO. C.`l NO. L�Q
permit is issued, 1 shall not employ any person in any manner �. SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS l CONDITIONS O
Date Applicant'
CITY i-.0 ZIP . .. ) Im
ARCHITECT O yy�� TEL. DISTRICT .. GROUP• TYPE.- ' FIRE PRO ESSED BY10
NOTICE TO APPLICANT: If, after' making this Certificate of ENGINEER 1-I... . NO. CONST. ZONE g�j
Exemption,'you should become subject'•to the- Workers' ^� �p� ,`
Compensation provisions of the Labor Code,''you must forth- ADDRESS JS-Od" �` G� 13 '
with comply.with such provisions or.this-,permit shall beAPT. CON
TEL.' �— TO STATISTICAL CLASSIFICATION DO. y
deemed revoked. CONTRACTOR NO. dr, -
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that Farn licensed under provisions of Chapter 9 I ADDRESS NO. SEWER MAPG*�,(commencing with Section 7000)of Division 3 of the Business and 1 LIC.
Professions.Code,'and my license is in full force and effect. i CITY Tem le Clt CA 1 8� CLASS B BKVALIDATION
SQ.FT. _ NO.OF,: NO:OF..._ CHECK
License Number 451865 ,L�c: a s B SIZE STORIES FAMILIES ONE '
tS111��e Y S VALUATION :..
Contractor D & W Associate Date DESCRIPTION OF WORK (;' _W-
Contractor
D' ❑'4• $ fJ/
I am exempt under Sec. ❑ I[�`j C.v ,
ALTER ❑'
B.BP.C. for this reason REPAIRUSE $"
Date:' EXISTOING BLDG. �/ 1 ! �Vl DEMOL ❑
Signature i APPLICANT 1n, f EL f�J — FINAL
g I PRINT V V' u�l� O: ��� J 5 4 5.�. .
OWNER-BUILDER DECLARATION DATE
I herebyaffirm that I am exempt from the Contractor's License q6(0-+-
r
Law fothe following reasori(Section 7031.5, Business and ! ADDRESS�1®�D�C� I�TtJ FINAL
Professions Code): PRESENT n BY : T
J BUILDING ,. L 3 t
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING- L, TEL D�• ,;..; C — ?U.
I, as owner of the property,am exclusively contracting CONTRACTOR W 5 DJO.
with licensed-contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
� �W� G• J � y
REQUIRED YARD HWY .TOTAL-SETBACK FROM
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
m P.L.
Q Lender's Name Q C�p'/_3LDLD"Ref. #
P.C.Fee$ Permit Fee
Lender's Address
xI certify that I have read this application and state that the - - Issuance Fee U C) kLD ' P/C# -
above information is correct. 1 agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee - 3 LDMA Perm. #
and hereby authorize representatives of this County to enter -
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
o
Signature o Applicant,or Agent Date Oo r
. I