HomeMy Public PortalAbout6246 MUSCATEL AVE_Building__ t
WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION F OI L D I N G PERMIT
insure,or a certificate of"Workers"Compenstion Insurance,or
a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELS BUILDING AND SAFETY
BOILDIPolicy No. Company
NG
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ` ADDRESS i
Elf�]Certified copy is filed with the county building inspec- BUILDING -
tion department. ADDRESS tlo �� /tJ, �`I L/S c,4-7—,e /t LOCALITY
NEAREST
S J
Date Applicant CITY �v C-1q-1 K1 I ( ZIP / 7 7 S CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT J� X�.� J NOW ON LOT MAPNO OF BLDGS. PAGE PARCEL
SOR
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one I —c-� ,rRrVSZ�5MAPDhundred dollars($100)or less.) TRACT J BLOCK LOT NO. Npi—rte TEL. SPECIAL CLI certify that in the performance of the work for which this OWNER r1C/ A-5 17. 1� [/�2 ��� j --6( CODITIONS
permit is issued, I shall not employ any person in any manner // Iu� �t GROUP TYPEFIRE PROC ED BY 0so as to become subject to the Workers'Compensation Laws. ADDRESS 6 Zt-/(v lU - /'� L( ('/d— Q F-r V P CONST E 99CITY S� iv 9 F7- i f ZIP 77,5
Date Applicant STATISTICAL CLASS ICATION APT. CONDO.
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. o� ul
Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWg5 MAP
with comply with such provisions or this permit shall be
deemed revoked. TEL. g , PG,
`!lam• VALIDATION
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALU ON
(commencing with Section 7000)of Division 3 of the Business and LIC. d
Professions Code, and my license is in full force and effect. CITY CLASS $ v�
SQ. FT. NO.OF , NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK
NEW ❑ $
❑ ADD ❑
I am exempt from the licensing requirements as I am a /
licensed architect or a registered professional engineer ALTER I FINAL
acting in my professional capacity (Section 7051, 1 SDATE (r `
REPAIR ❑
Business and Professions Code). USE OF DEMOL FINAL
EXISTING BLDG. ❑ }
Lic.or Reg.No. Date APPLICANT_� TEL.
OWNER-BUILDER DECLARATION PRA
INT .C 4 1,,13P 0 rZ J N0.19'(„-3 1 .
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS .L Y(, - L(5 C-1--J -e
Professions Code): PRESENT
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 ` 0 4 8,8 A
7044, Business and Professions Code). MOVING TEL.
❑ CONTRACTOR NO.
I, as owner of the property, am exclusively contracting �? 0 0 0 0. 0 1
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). 2 - 3400
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT o 0 0 3 IL 0 0
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE o 7.2 4-8 1
P.L.
Lender's Name �
° Lender's Address P.C. Fee 5 Permit F
I certifythat I have read this application and state that the
@ PP Issuance Fee
above information is correct. I agree to comply with all County Investigation Fee
3 ordinances and State laws relating to building construction, Total Fe
° and hereby authorize representatives of this County to enter
upon thea ove-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent to
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