HomeMy Public PortalAbout6408 OAK AVE_Building__ + , WORKERS'COMPENSATION DECLARATION
, u reby affirm that I have certificate of consent to self
insL I CATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified co is hereby furnished. . FT� AN TO FILL IN BUILDING
PY y �'..ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
ESS
tion department. �7 Date Applicant ESS
CITYrZIP �� �/ <LOCALITYCERTIFICATE OF EXEMPTION FROM WORKERS' O. OF BLD T NEAREST
k SIZE OF LOTOW ON LOT ` CROSS 57.
COMPENSATION INSURANCE ASSESSORP�(Thissection need not be completed if the permit is for one TRACT LOT NO. 'MAP BOOKO , PAGEG�� PARCEL 04IZ.hundred dollars ($100)or less.) TEL.OWNER � NO• —,,j j ?,USE ZONE MAP / �I certify that in the performance of the work for which this NO4>permit is issued, I shall not employ any person in any manner ADDRESS FRIAL
. TIONSso as to become subject to the Workers'Compe ation Laws. , Gr/ O
CITY _e @ ZIP ,71;d 0 " U
Date��'I9"-71 Applicant ARCHITECT RTEL.
NOTICE TO APPLICANT: If, after makingthis -ertifi a of ENGINEER NO. DISTRICT GROUP TYPE FIRE P CESSED BY
CONST. ZONE 0
Exemption, you should become subject to the Workers' U
Compensation provisions of the Labor Code, you must forth- 4,ADDRESS :z �Q� -3 v pw_•
with comply with such provisions or this permit shall be ; TEL. .j:,STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR NO. � // _
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. C-22-2-1 UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the BusinessLIC. SEWER MAP
and Professions Code,and my license is in full force and effect. s CITY CLASS Y BK PG VALIDATION
SQ. FT. NO.OF NO.OF CHECK
License Number Lic. Class SIZE I STORIES FAMILIES ONE
DESCRIPTION OF WORK � NEW Q VALUATION
Contractor Date. $
' ❑
Elam exempt under Sec. � !t S ieLG •e ADD '
ALTER ❑
B.&P.C, for this reason ! $
REPAIR ❑ ':
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. / 7(PRINT)
FINAL
OWNER-BUILDER DECLARATION DATE
5
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL -7- '
Professions Code): ' PRESENT By - _ _
.® BUILDING y Ch7L:
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
_t_I
the structure is not intended or offered for sale(Section LOCALITY � 'AL 101733 „_ 6:3
7044, Business and Professions Code.) MOVING TEL. ® u t• -
NO. +EF •E■ 3_+.=L'•�
❑ I,as owner of the property,am exclusively contracting CONTRACTOR i,�
with licensed contractors to construct the project (Sec- ADDRESS pz E'�rti gtj' "I`
tion 7044, Business and Professions Code.)
REQUIREDTOTAL 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 I i LTI —!-TY!
the performance of the work for which this permit is issued P.L.
(Sec. 3097, CIV. C.). SIDE " r),•'ti t„�
P.L.
Lender's Name
LDMA Ref. q
Lender's Address P.C. Fee$
Permit Fee o ,
' I certify that I have read this application and state that the Issuance Fee LDMA P/C#
above information is correct.I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee Q LDMA Perm. #
( and hereby authorize representatives of this County to enter
upo the above-me tione property r inspection.purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of 9 plicant Agent Date 3v Seu� a A<4