HomeMy Public PortalAbout6000 OAK AVE_Building__ WORKERS COMPENSATION DECLARATION
h9j; offvrg that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT
msui certificate of Workers Compensation Insurance
or d ified copy thereof(Sec 3800 lab C) COUNTY OF LOS ANGELES VALDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN moms e► o tink
❑ Certified copy is filed with the county budding mspec BUILDING I.,vow
tion department ADDRESS
Date Applicant CITY L*/ ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LOT �ON LOT QST
COMPENSATION INSURANCE ASSESSOR
CROSS ST
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO MAP PAGE PARCEL
hundred dollars($100)or less) OWNER ,� TE
U N MAP
1 certify that in the performance of the work for which this
INO
permit is issued I shall not employ any person to any manner ADDRESS OSONDmO1V5
so as to become subject to the Workers Compensation Laws O
1CITY ZIP 47/73 V
Date '� Applicant j• C�sssw/a� ARCHITECT OR TEL of
NOTICEO AP ICA If after making this Certificate of ENGINEER NO DISTRICT TYPE �� FIRE PROCESSED BY
Exemption you should become subject to the Workers �. CONST' L/ E V
Compensation provisions of the Labor Code you must forth ADDRESS vo �-�
with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO h
deemed revoked CONTRACTOR NO Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS
NO(commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP
and Professions Code and my license is to full force and effect CI � NO � � OFCLASS CHECK BK PG VALIDATION
License Number 4c Class SIZE STORIES FAMILIES ONE qr
v.0, / a
Contractor Date oEscRIPrION OF WORK NEW 11 $ L, /
• 2 ►
❑I am exempt under Sec
ALTER ❑
B&P C for this reason ,USE OF PAIR ❑ $
Date EXISTING BLDG DEMOL ❑
Signature APPLICANT� t FINAL
OWNER BUILDER DECLARATION DATEI hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 5 Business and ADDRESS FINAL 1
Professions Code) PRESENT By AMT 31
❑ I as owner of the property or my employees with
BUILDING
wages as their sole compensation will do the work and Vy Wv 307 290.25
the structure is not intended or offered for sale(Section LOCALITY 1 ims
7044 Business and Professions Code) MOVING TEL
❑ I as owner of the property am exclusively contracting CONTRACTOR NO TATA, 290.25
with licensed contractors to construct the protect(Sec ADDRESS
tion 7044 Business and Professions Cade) OE(* 290.25
CONSTRUCTION LENDING AGENCY CALKED YARD HWY 70TAL SETBACK FROM EXIST
I hereby affirm that there is a construction tending agency for FRONT
PROP LINE WIDTH .00
the performance of the work for which this permit is issued PL
(Sec 3097 Civ C) SIDE
Lender's Name LDMA Ref 1 re 1 9•1 10/24/89
5 Ir
lender:Address PC Fee Permit Fee b�JS •
o 53
I certify that I have read this application and state that the Issuance Fee 10, LDMA P/C M
above information is correct I agree to comply with all County Investigation Fee 0
ordinances and State laws relating to building construction Tarot Fee a 9 25 L)AAA Perm tf
and hereby authorize representatives of this County to enter
upon he above men�7onediro arty for inspection p
IEE RlVER6E POR EXPLANATORY LANGUAGE
Signature of Applicant or Agent