HomeMy Public PortalAbout6223 OAK AVE_Building__ WORKERS'COMPENSATION DECLARATION
' ue affirm that I have certificate of consent to self
i APPLICATION FOR I�U I L D I N G PERMIT
insure, oe, or a certificate of Workers'Compensation Insurance, ,
or a certified copy thereof(Sec. 3800, Lab. C:) '
. COUNTY OF LOS ANGELES ' ^BUILDING AND SAFETY
p /4.24.1106�3a�tt�ony_ Argonaut In I '
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN - ADDRESS
® Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS 6 23. :N;or•.t h. Oak LOCALITY
1-11=•8 4
Temple-e- C it .5178Q NEAREST
Date . Applicant' Ran d o 1 Ro o f in CITY P. Y zipCROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ' USE NE MAP
hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO.
0103
TEL SPECIAL
I certify that in the performance of the work for which this OWNER. .Jack.. L i.t t 1 e N(° 8 5,5 6 4 9 CONDITIONS 9L
permit is issued,I•shall not employ.any person in any manner I DISTRICT GROUP TYPE FIRE ,. PRO SSED BY O
so as to become subject to the Workers'Compensation Laws. I ADDRESS rat 23' .N • O a1C. ' I'�� v A-3
CONST. ZONE lJ
I CITY •T'em .lee `.0 i.t zip .917 8 0 V 100
Date 10-9-84 Applicant Ran d o 1 Ro o f in 1; P y sr�TISTICAL CLASSI ICATION APT. , CON �
NOTICE TO APPLICANT: If,. after making this Certifitate of I ARCHITECT OR TEL.
O'. DWELL UNITS
ENGINEER NO. LASS NA.
'Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ; ADDRESS SEWER MAP
with comply with such'provisions or this Permit•.shall be
deemed revoked. CONTRACTOR Ra.n d o 1 R 0 f in g Not 88,4040. BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION i 5 2 9. .E.. 'V a 11 e B 1 .LIC. �69l 3
I hereby affirm that I am licensed under provisions of Chapter ADDRESS N04�r 1 3 7 VALUATION. 1
Section 7000 of Division 3 of the Business and I• I
(commencing-with ) San 'Qahri.el UC.- C=39 �$ 5928.00
Professions.Code,and my license.19 in full force and effect. CITY CLASS Pilo
$Q:FT. NO.OF NO.OF CHECK"
License Number 4 5 19-4 7 Lia Class C'-3'9 ': SIZE STORIES FAMILIES ONE ii. gg 33 gg
DESCRIPTION OF.WORK ' I n s t a l l V in•y 1 NEW E] I($ '� a.0'8 3 8 U
Contractor Rando,l Roofi.n�}e 1Q-9-84 i ., ,. ..
siding on house. ADD ❑ I Q.1 7-84
❑ I am exempt under Sec. "'
r ALTERFINAL
DATE —Z
REPAIR
B.BP.C. for this reason ❑y
USE OF 'FIN
Date: EXISTING
BLDG. '8 F D DEMOL ❑, GE?.
r APP9y
Signature APPLICANT TEL. '
OWNER-BUILDER DECLARATION (PRINT). NO.
I hereb affirm that I am exem t from the Contractor's License
Law for the following,reason (Section 7031:5, Business and'' ADDRESSe''' r
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 r
the structure is not intended or offered for sale(Section LOCALITY �� �/ �" •� ' ?
n r .
7044, Business and Professions.Code). MOVING, TEL. �'.�,sL�r��i4 4 f �- i
❑ property,rty, I CONTRACTOR NO. r' -
I, as owner of the roe am exclusiyel contracting .�• r
with licensed contractors to construct the project (Sec- 4 ADDRESS
'tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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 1
I
Lender's Name l "
P.C.Fee$ Permit Fee 7 6 8 8 L
- Lender's Address
r I certify that I have read this application and state that the 1 0•.5 0•
� Issuance Fee
above information is correct. I agree to comply with.all County Investigation Fee
ordinances and State laws relating to building construction I Total Fee R7 ••38
J and her authorize representatives of this County to enter
upon thepb)oye-mJPntio prop ty, i r inspect' n purposes.
i
SEE REVERSE FOR EXPLANATORY LANGUAGE I _
Signature of Appliccnt or Agent D tev