HomeMy Public PortalAbout6384 OAK AVE_Building__ k . WORKERS COMPLNSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION. F®RBUILDING PERMIT
insure, or a certificate of Workers'Compensfion Insurance,or
a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nom'`�— '9/ Company
❑ Certified copy is hereby furnis ed. FOR APPLICANT TO FILL IN BUILDING
ADDRESS �
F-1Certified copy is.filed with the county building inspec- BUILDING
tion department. ADDRESS LOCALITY
NEAR ST
Date Applicant CITY ZIP CROSS ST.' sti
CERTIFICATE OF EXEMPTION FROM WORKERS' NN NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT v ^ W ON LOT .L 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 J-• LOT NO. O NO.
TEL. `� PP
SPECIAL p„
OWNER O� / I CONDITIONS
I certify that in the performance of the work for which this O
DISTRICT GROUP TYPE FIRE PROCESSED B V
permit is issued, I shall not employ any person in any manner .r
ADDRESS � . r/ CONST. ZONE
so as to become subject to the Workers'Compensation Laws. + 3 Q
DateCITY ZIP
Applicant STATISTICAL CLASSIFICATION APT. CONDO.
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL,
Ly
Exemption, you should become subject to the Workers' ENGINEER NO.� of CLASS NO. / DWELL. UNITS 0.
Compensation provisions of the Labor Code, you must forth-
ADDRESS 3 , SEWER MAP
with comply with such provisions or this permit shall be TEL.
deemed revoked. CONTRACTOR • NO. Qta BK. PG,2 3 VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
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 $ ?
SQ. FT. NO.OF NO.OF CHECK
,
License Numb Lic.Lic.Class_ _ SIZE STORIES IFAMILIES ONE
Contractor�A5� Date DESCRIPTION OF WORK NEW ❑' ,f
❑ ADD ❑ /6—
Iam exemQt from the licensing requirements as I am a ��licensed architect or a registered professional engineer ALTER ❑ FINAL >acting in my professional capacity (Section 7051, REPAIRDATE Business and Professions Code). USE OFFINAL EXISTING BLDG. DEMOL ❑ B Lic.or Reg.No. Date APPLICANT T L, yOWNER-BUILDER DECLARATION PRINT) . r� . .
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS /1, ]
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY o7044, Business and Professions Code). MOVING TEL.
I, as owner of the property, am exclusively contracting CONTRACTOR NO. 0with licensed contractors to construct the project (Sec- ADDRESStion 7044, Business and Professions Code). •a oREQUIRED 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 ( 0.
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
�l
sa _ o ra -:
Lender's Address — o N
P.C. Fee$ Permit Fee OV O c o o n O o 0
a x
I certify that I have read this application and state that the /�` �Ll� O � � o O 'V
above information is correct. I agree to comply with all Count r Issuance Fee �. O` IU IU o •R P W C!J \
9 P Y y Investigation FeeP0/L U � o
ordinances and State laws relating to building construction, q�.�(or(� 7 Total Fee 10U Xn 44 Oo ct1 01 o O CC) O O
C
and hereby authorize representatives of this County to enter CD O - r
upon th abov i ed pr perty for inspection purposes.
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��� SEE REVERSE FOR EXPLANATORY LANGUAGE
Sin Lure of Bpplicant or ent ate ®s
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