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HomeMy Public PortalAbout5005 PAL MAL AVE_Building__ WORKERS' COMPENSATION DECLARATION I` re,o affirm that I have certificate of consent to self APPLICATION FOR" .BMJ I L D I N G P E RM I T w insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGLES w BUILDING AND SAFETY Policy No. Company ❑ Certified co is hereby furnished. FOR APPLICANT TO FILL IN BUILDING PY Y �ADDRESS ❑ Certified copy is filed with the county building inspec- ADDRESS =j ft b / �L .,Q(� tion department. CITY , b !v ZIP G LOCALITY �L Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCEASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. t- MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) OWNER Jc" L TEL..J/ifJ�U��n USE ZONE MAP I certify that in the performance of the work for which this NO. SPECIAL >_ permit is issued, I shall not employ any person in any manner ADDRESS 6 CONDITIONS a so as to become subject to the Workers'Compensation Laws. OO CITY ZIP Date Applicant ARCHITECT OR Y TEL. DISTRICT NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO GROUP TYPE FIRE CESSED BY 0 Q "Keg ff CL Exemption, you should become subject to the Workers' w Compensation provisions of the Labor Code, you must forth- ADDRESS o. with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION A . CONDO. 'Z , deemed revoked. CONTRACTOR NO. _ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.w2 UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO. OF NO.OF CHECK License Number Lic. Class SIZE I STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW $ ❑1 am exempt under Sec. L& "Ck ADD ❑ of �cpoll ALTER ❑ B.BP.C. for this reason at l REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE �•ZS I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT B © I, as owner of the property, or m employees with BUILDING y ACCTA P P Y� Y -. r wages as their sole compensation,will do the work and ADDRESS 3303 127.65 the structure is not intended or offered for sale(Section LOCALITY e 7044, Business and Professions Code.) MOVING TEL. 1 ITEMS ❑ I,as owner of the property,am exclusively contracting CONTRACTOR No TOTAL 127 o 6-5 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) CHECK 127.65 REQUIRED TOTAL SETBACK FROM EXIST. CHANGE o00 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 Lender's Name P.L. 0000-0001 7/26/96 a LDMA Ref.q 7694 1 Ai�11�4 Lender's Address P.C. Fee$ Permit Fee 1 certify that I have read this application and state that the Issuance Fee •/ LDMA P/C N 00. 3 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee /.V LDMA Perm. #i and hereby authorize representatives of this County to enter upon t e above-mentioned property for inspection purposes. y o �7_AQj,4 T7 SEE REVERSE FOR EXPLANATORY LANGUAGE gnature o Applicant or Agent Date