HomeMy Public PortalAbout5219 PAL MAL AVE_Building__ WORKERS' COMPENSATION DECLARATION
�I hereby affirm ifica I have certificate of consent to self A P P L I C►AT I O N FOR BOI L D I M I T
insure, or a ceJfificate of Workers' Compensation Insurance,
or a Certified copy thereof(Sec. 3800, Lab. C.) COr NTY OF LOS ANGELri BUILDING AND SAFETY
Policy No. Company BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 7rL rlr >
❑ Certified copy is filed with the county building inspec- BUILDING �1 0[ A
tion department. ADDRESS' 1 .�,, fu �' l�-��j
cFW \'^AMfW—= C" ti ° ZIP r ..::LOCALITY
Date Applicant NO.OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT X NOW ON LOT d ". CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT 12-400 5 BLOCK LOT NO. MAP BOOK PAGE L'o?o2 PARCEL ��-
hundred dollars ($100)or less.) TEL
OWNER NO.�lr7" USE ZONE MAP
NO.
I certify that in the performance of the work for which this � ,,/ SPECIAL >-
permit is issued, I shall not employ any person in any manner ADDRESS ` �L- CONDITIONS CL
soas to become subject to the Workers'Compensation Laws. O
CITYT b L ZIP
Date Applicant ARCHITECT O TEL.
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEERO. 1 DISTRICT GROUP CONST. ZONE FIRE PROCESSED BYQ�-
Exemption, you should become subject to the Workers' / W
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be f TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTOR NO. Z
LICENSED CONTRACTORS DECLARATION LIC. CLAS$NO.—,:;21 DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9fEXISTING
SS NO.
(commencing with Section 7000)of Division 3 of the Business
LIC. SEWER MAP
and Professions Code,and my license is in full force and effect CLASS BK t�/ALIDATION
.� NO. OF NO.OF CHECK -= tJ
License Number Lic. Class STORIES FAMILIES ONE
• VALUATION ACCT.
�
Contractor Date PTION OF WORK "(� NEW ❑
�
❑I am exempt under Sec. .•6)t—�{ cave, �„ �� ADD ; ` ► 3`�r
1 ALTER ❑ 1 ITEflS
BAP.C. for this reason t T O REPAIR ❑ $ TOTAL 846,E o ��
Date: USE BLDG. DEMOL ❑ [ { Ct/ Q[
9.55
Signature APPLICANT TEL R
g OWNER-BUILDER DECLARATION (PRINT) O � FINAL t' � 00
DATEI hereby affirm that I am exempt from the Contractors License ADDRESS �;/�1-- _z o
Law for the following reason (Section 7031.5, Business and FINAL nt
Professions Code): BUILDING�� GQ �jbl� yti'� By t-t�i 9� 3/92
EJ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and �-�+��,.pp � INN 1
the structure is not intended or offered for sale(Section LOCALITY s --'VV► 1-�
7044, Business and Professions Code.) MOVING TEL. , I ITEM'
I,as owner of the property,am exclusively contracting CONTRACTOR NO. TOTAL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) 'CHECK 1[I'�F.,r!
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 CHANGE
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
LenderP.L.s Name 0000-00101 6/155/9"T
LDMA Ref.# •�f
P.C. Fee$ •ob Permit Fee d/� �.7 , 0--46 1 AM102,L
Lender's Address
r +1
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 CountyInvestigation Fee
ordinances and State laws relating to building construction, Total Fee • LDMA Perm. #
and hereby authorize representatives of this County to enter
upon th above- ntioned property for inspection purposes.
6-r P- 3 SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applicant or Agent Date