HomeMy Public PortalAbout5831 OAK AVE_Building__ 1
WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of coInsur s+ r }L I CATION FOR BUILDING PERMIT
insure or a certificate of Workers Compenstion Insurancc o
e or
a certified copy thereof (Sec 3800 Lob C ) T COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company BUILDING
Fq
Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec BUILDING
tion department ADDRESS ✓ `r� LOCALITY
w M/�� NEAREST
Date Applicant CITY (� ZIP W�p CROSS 5T
CERTIFICATE OF EXEMPTION FROM WORKERS e NO OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT �6 5 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 LOT NO NO }
rr-- '' TEL SPECIAL d
I certify that in the performance of the work for which this OWNER WJt 1 NO CONDITIONS O
permit is issued I shall not employ any person in any manner C ISTRICT GROUP TYPE FIRE PROCESSED BY l)
so as to become subject to the Workers\Compen2sation Laws ADDRESS .! E CONST ZONE O
I Q `JIV v'4. "�70G_. [CONDO ~
Date Applicant CITY �. ZIP ��� STATISTICAL CLASSIFICATION � APT U
NOTICE TO APPLICANT If after makingthis Certificate of ARCHITECT OR TEL W
916
ENGINEER NO CLASS NO _DWELL UNITS
Exemption you should become subject to the Workers z
Compensation provisions of the Labor Code you must forth ADDRESS , SEWER MAP
with comply with such provisions or this permit shall be n
deemed revoked CONTRACTOR1r 614 N L BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION LICI hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION(commencing with Section 7000)of Division 3 of the Business and LICProfessions Code and my license is in full force and effect CITY tl CLASS $
NO OF NO
LicenseNumber ` Lic Class�rSIZEFT1p S ORIIES FAMILLIIES CONEK ��Contracfoi �+ Date I DESCRIPTION OF WORK -Gw NEW $ f V ZC7
am exempt from the licensing requirements as I am a ' a�y`r ADD Zicensed architect or a registered professional engineer ALTER ❑ DA EFINAL17 Ll acting in my professional capacity (Section 705) REPAIR Business and Professions Code) USE OFEXISTING BLDG •fit DEMOL ByALyX5 4 b 6 q
Lic or Reg No Date APPLICANT /� TEL
OWNER BUILDER DECLARATION (PRINT) (:. fJ NO "� eit j L 7i
I hereby affirm that I am exempt from the Contractor s License ADDRESS�� SAA �i D I 1 O 8 O O
Law for the following reason (Section 7031 5 Business and °
Professions Code) BPRESENT
UILDING i ° ° J C)G I;f i cs
I as owner of the property or my employees with ADDRESS ,
wages as their sole compensation will do the work and moi$ 0 e 1 —82
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING TEL 15 9 6 7 P
I as owner of the property am exclusively contracting i CONTRACTOR NO
with licensed contractors to construct the project (Sec ADDRESS # 0 0 o a 0 1
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPREOTP LINE WIDTH
WIDTH C t 2 ° 497 )O
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 o n7C)1
(Sec 3097 Civ C ) SIDE % � i-g (�•
Lender s Name P L 0 31 —32
r
Lender s Address P C Fees Perm t Fee
I certify that I have read this application and state that the i �0 Issuance Fee rr
aabove information is correct I agree to comply with all County Investigation Fee
$ ordinances and State laws relating to building construction Total Fee
and hereby authorize representatives of this County to enter
up n the abovpoWntioned property for inspection purposes
(/vim f SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Appl cant or Agent Do i