HomeMy Public PortalAbout5013 PAL MAL AVE_Building__ WORKERS' COMPENSATION DECLARATION
I hereaffirm th
insure, or a certif carte of Workers' C mpensat on Insurance, APPLICATION FOR BUILDING P E RM I T
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN .,ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING �� 1 11Q M Q
tion department. ADDRESS ! I `
Date Applicant CITY I e ZIP / 7 FC LOCALITY �!Lc
OF BLDGS. NEAREST
CERTIFICATE-OF EXEMPTION FROM WORKERS'' SIZE OF LOT '7 7 NOW ON LOT CROSS ST. 61,
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK 9546.57PAGE PARCEL
hundred dollars ($100)ori less.) TEL/d)_11cq/�
OWNER � h C h NO. D USE ZONE OP 1417
9
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS �® q o �, / SPECIAL a-
CONDITIONS
so as to become subject to the Workers Compensation Laws. � t � �
CITY t2 ZIP 9 l-7 $o
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYy[ FIRE OCE. BY
Exemption; you should become subject to the Workers' f� n- ��fiNrg�L ZONE W
Compensation provisions of the Labor Code, you must forth- ADDRESS SO' I (L
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. v7
deemed revoked. CONTRACTOR NO. Z
LICENSED.CONTRACTORS::DECLARATION LIC. CLASS NO. DWELL. 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 SIR STORIES FAMILIES ONE
VALUATION
Contractor Date E l PTIONN OF WORK �G+5 U L t^ NEW ❑ $ 0 p 0
ADD LJB ,
❑1 am exempt under Sec. �� �P' ®(J�"`
ALTER _
B.BP.C.'for this reason' t° Y` ,��j'',,'.,,1 � y /�Q a REPAIR $
tk+te: USE O 1 «' U E G l�
EXISTING BLDG. G h DE�,M/OL ❑
Signature. APPLICAPRINNT
p v'`�' NO. 3 b FINAL
OWNER-BUILDER DECLARATION n r ,
I hereby affirm that I am exempt from the Contractor's License DATE
ADDRESS /—Q �4 l '
Law for the following reason (Section.7031.5, Business and FINA
Professions Code): PRESENT S0 r n4 a l By
Ly�I,'as owner of the roe or m 'em to ees with BUILDING L /—
P property, Y P Y ADDRESS ' qq
wages as their sole compensatton,.will do the work and % •=Ul
the structure is not intended,or offered for sale(Section LOCALITY Cp C t eq r
7044, Business and Professions Code.) MOVING ..TEL.
❑ I,as owner of the property,am exclusively contracting CONTRACTOR 'NO. _
with licensed contractors to construct the project (Sec- - ---r'-'
tion 7044, Business and Professions Code.) ADDRESS _
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH --
Ihereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.C.'
(Sec. 3097, Civ. C.). SIDE -
P.L.
Lenders'Name �� d7
LDMA Ref. #
P.C. Fee$ Permit Fee -
Lender's Address
I certify that I have read this application and state that the Issuance Fee �� L•Y LDMA P/C#
3 above information is correct. I agree to comply with all County Investigation'Fee
ordinances-and State laws-relating to building construction, Total Fee (J so LDMA Perm. #
c and hereby authorize representatives of this County to enter, ^
. upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
' Sig-nature of Applicant or Agent Date