HomeMy Public PortalAbout6350 OAK AVE_Building__ Y 1�WORKERS'COMPENSATION DECLARATION
' I fier�by''affirm that I have a certificate of consent to self
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insure,or a certificate of Worker's'Compenstio Insurancq or , A P P L I CATION FOR • BUILDING -. PERMIT .
.a certified t ereof(Sec, 800-Lab. C. 4
� q` // �� COUNTY OF LOS ANGELES BUILDING AND SAFETY
i Policy No f+ / f^i/at�ompa4 ( n� J ' -
❑ Certified copy is'hereby furnished. FOR APPLICANT TO FILL IN BUILDING n
ADDRESS.
Certified copy is filed with the pounty building inspec- BUILDING 1-7 -�
tion department. ADDRESS J LOCALITY
i NEAREST
Date Applicant CITY, , li. ZIP. CROSS ST.
ERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR „•
COMPENSATION INSURANCE SIZE OF-LOT.- NOW,ON LOT- MAP BOOK PAGE ARCEL 4' '
(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. C�
SPECIAL
I certify that in Yhe'performance of the work for which this OWNER o. CL f%`� CONDITIONS
/� DISTRICT GROUP TYPE FIRE ' PROCESSED BY` V
permit-is issued,,I shall not employ any person,in any manner ADDRESS fy l CONST. ZONE
so as to become subject td the Workers'Compensation Laws. /)
Date Applicant' CITY ZIP / STATISTICAL CLASSIFICATION APT.ARCHITECT OR _ TEL. Q h J ]CONDO.
- LU
NOTICE TO APPLICANT: If, after making this Certificate 'of ENGINEER•. j NO. ,� ��2 CLASS NO.�r - DWELL.UNITS
Exemption, you should become .subject to the Workers'• N
Compensation provisions-of the Labor Code; you,must forth- ADDRESS `f `, t SEWER MAP
with comply with 'such'provisions or this'permiv shall be TEL '
deemed revoked. VALIDATION
CONTRACTOR S, 6 NO.
cA rV BK. PG,,
LICENSED CONTRACTORS DECLARATION LIC. J
I 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 LIC.
Professions Code,and my license is in full force:and effect. CITY CLASS - / $ '• -
n SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
�j •' DESCRIPTION OF WORK
NEW $ !
Contractor • ate ❑ '
❑ I am exempt from the licen§ing requirements as I am a ADD +
licensed architect or a registered professional engineer , L. ALTER ❑ FINAL.1 • � ,.
acting �ih my professional ,capacity (Section 7051,
REPAIR
s anProessions- DATE r•4 2�`'9t A
Businesd fCode. ❑ O
' t ) USE OF FINAL }'o n.u!a
EXISTING BLDG. DEMOL ❑ By
Lic.or•Re No. _Date APPLICANT �' TEL. o ;•:`> ! �'( '
g + (PRINT NO. � `Lt
OWNER-BUILDER DECLARATION /
I hereby affirm that I-am exempt from the Contractor's License - �C r_ . - a
Law for-th'e_following reason (Section 7031.5, Business and ADDRESS rr )
Professions Code): PRESS J -0 8'-C 2
❑ BUILDING
I, as owner of The property,'or my employees with ADDRESS -
wages as their sole compensation;will do the work and
i the structure is not intended or offered for sale(Section LOCALITY ;
7044, Business and Professions Code). MOVING TEL.
I, as owner of the property, am exclusively contraCONTRACTOR NO.
contracting CONTRACTOR 3 a 0 A
with licensed contractors to construct the...project (Sec-
ti
Sec- ADDRESS
tion 7044, Business and Professions Code). o o•o o•v
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 c' /I 37.50
the performance-of the work for which this'permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE v'c
,q('/J
P.L.
Cendees Name_��/�
Lender's Address P.C. Fee Permit Fee
I 1 certify that I have read this application and state that the Issuance Fee > •J
above information is correct. I agree'to comply with all County Investigation Fee 7 -�
ordinances and State-laws relating to building construe)ion, - Total Fee J /i
he, a
and hby authorize represent es of this County to enter t
u
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p �y for inspect„ion urpos s. roY CP® G L / f. SEE REVERSE OR EXPLANATORY LANGUAGE
o .
�• A ignatu e of A pl,canf or Agqnf te ®s',