HomeMy Public PortalAbout6242 MUSCATEL AVE_Building__ f WORKERS'COMPENSATION DECLARATION
411-her-$M affirm that I have certificate of consent to self L I CAT F O 3 I L®I N G I T
insures; or a certificate of Workers'Compensation Insurance,
ora certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS
BUILDING (_/
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- BUILDING ��jj
tion department. ADDRESS oc •
!'
Date Applicant CITY (!��W ZIP � •:LOCALITY /
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR
hundred dollars($100)or less.) MAP BOOK PAGE PARCEL
ten,/ /� TEL. ��_ (, —
OWNER LCG Grs�t //���i� NY
h USE�ONE MAP
I certify that in the performance of the work for which this NO. .�.�
permit is issued, I shall not employ any person in any manner /�i,`r� SPECIAL
so as to become subject to the Workers'C mpensat on Law ADDRESSCOoc T �/a���y /7 1 CONDITIONS 0
—r CITY ZIP Vl/�F y U
Date 44--6;2 r Applicant n:
L.
NOTICE TO APPLICANT: If, after making is Certificate f ARCHITECT O ENGINEER NO. DISTRICT I GFqUP TYPE FIRE PRO ESSED BY O
^ CONST. ZONE V
Exemption, you should become subject to the Workers' t' _�/
Compensation provisions of the Labor Code, you must forth- ADDRESS -�t(/ w
with comply with such provisions or this permit shall be
k 9
deemed revoked. TEL• STATISTICAL CLASSIFICATION APT. LONDO. rCONTRACTOR C / !/ft; NO.rJ9/BSdtS" Z
LICENSED CONTRACTORS DECLARATIONryQ// ��``�� LIC,ff//x CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Obi /ZT/L NO.T .33 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITYtilf CLASS � BK PG VALIDATION
Lic.Class-3SQ.FT. NO.OF NO.OF CHECK
License NumberSIZE STORIES FAMILIES ONE
VALUATION
Contractor-(:"'-
ontractor(: � / DESCRIPTION OF WORK /�+ J NEW 0
ADD ❑ S—/��+ ��'/21�"� pate /4&Z/,F-7
^�1� ❑ V CC ,
1 am exempt under Sec. �l/e
ALTER ❑
B.BP.C. for this reason REPAIR $ 8 2 2 6 A
Date: USE OF DEMOL
EXISTING BLDG. # 0 0 0 0 0
Signature APPLICANTTEL. FINAL
OWNER-BUILDER DECLARATION (PRINT)
PRINT NO. DATE i Z — o 049,88
1 hereby affirm that I am exempt from the Contractor's License ADDRESS ° ° o49,880'
Law for the following reason (Section 7031.5, Business and FIN
Professions Code): R N By L'❑ Q28-87
BUILDING
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. lop
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).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL SETBACK
LIINE 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
/y l�
Lender's Name iP.L.
LDMA Ref. #
Lender's Address P.C.Fee$ Permit Fee ✓ y
L I certify that I have read this application and state that the Issuance Fee �5 V LDMA P/C R
3 above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Q�
and hereby uthorize representatives f this County to enter Total Fee U LDMA Perm.q
5 upon the a ve-mentioned proper r inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o pp icant or AgentFr— Date
DEPAR•PaOa\• I3V
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APPLICANT FILL IN 11SAVILY OUTLINED PORTION Oxley.•�: .�rs+CR+6, ---`*
1�•�e1 NAME • • •• ,r'-+�e��; ODDRq a is
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LICENSE NO Tim. NOOF
Ow ON LOT
CLASS OF WORK '�' YSw OP nom- •..:� r'
A Now ON LOT
NEW ADDITION A 09MOLION DS$CRIPTiON OF.RORK •F•
ALTERATION REPAIR MOVING •� _ , `'��,;•.''ti"• :t7 j.
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.PARTITIONSsay.Ia•s .r�.�.��„:� ' •.,:..-....-• ';`,C.itnr:!n..•t. !.• y�..' • +
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_.. DXPAItTMENT OF BVILDINA'AND 90M., ?AprLiC�1'IOl�FOE;PS1t3uT�;vim
d COUNTY OF IAS ANGELES' ;:; „�' �-� ,,.g•�: �� ,
TM. J. Poe. CHIRP VNIMM.
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APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
t`r`y NAME ADDRESS •"�'' i
_ A 49 LOCALITP'/ � I
b
CIT/ NEAREST
STATE c
LICENSE NO. TeL. me.�� QtjAM9 r d,•_ /f
• tQ ADD' _ MAIL
.. NAME Reel tf� - i
ADORnf CITY
TEL NO.
t
CITY A ✓' 991E O/LOT
STATE
LIC[Nff NO LewTR. NO Y R r NOO. Suse LOGS.
/+9•w�•
CLASS OF WORK A Nowpp ,f
• 'x
NMDESCRIPTIN OF WORN ADDITION DEMOLISH ,�
ALTERATION! REPAIR MOVING + .• I
s_
USE OP
9Loo.
9129 OF
SLIM. S •TOR ' NO. OP r
IAM ILI n 'COIulzcTIoNSA..
SPECIFICATIONS
FOUNDATION 0 W% e
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arm IN ODuNO ,I 4 3�n.s•.M»,1.7:T• '=..r•--' '•�+"' •_
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SUMZMRFRUCTUR
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R. PLATtt IIIILL '
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.kI1STf�NLOOR •p rtf'ir:'w '�'S
JOHTt_GEILING .+.
REARING WALL* - ••? _ _- ~
PARTITIONS
'POOP RAFTERS '
WILL 7OLTf • •— ,• .ir• MNAL APPROVAL
COVERING i' r.vfv !1 .'; '�•:•'
SAT[ '•IR[rRmwo RAM[
WALL /_♦�G�_A_�OO �.tw •1 N[R[RT.ACKNOWL[DO[ THAT 1 HAVE R[AEI 'di/
APPLICATION AND STATE 11 AT TN� � OVt If CDIIIItw
J AND AOR[ MPLT WITH ALLGf,'AF�NTT ORDOMNCL!
P.C. FEES AND S r TERICE101111W
a SIGN "� :��'S�;• 'lt
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