HomeMy Public PortalAbout5232 PAL MAL AVE_Building__ " -i "fir '=OMPENSATION DECI•ARATION /^ " COU � �bO�J *' / /���
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.,�11�I�+�e "ave a certificate of consent to self q p p L I C TION FOR BUILDING P E RM I T
insure, o, certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, lab. C.) COUNTY OF LOS'ANGELES BUILDING AND SAFETY
` Policy No. Company BUILDING2
ElCertifiedcopy is hereby furnished. LL FOR APPLICANT
JTO/jFILL IN ADDRESS / —
❑ tion Certified copy is filgd with the county building inspec- BUILDINGADDRESS J���� [r ll "/ /Jj�^
tion department.
Date Applicant CITY ZIP (/ LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' / /(�i / NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT D X /O C� NOW ON LOT �� CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
.hundred dollars($100)or less.) TRACT BLOCK/�/� LOT NO.�EL. �7/ �f MAP BOOK PAGE PARCEL
P J at1 NO. (/f�/ USE Z NE MAP 7^7J 9•
I certifythat in the performance of the work for which this OWNER r NO. Y
permit is issued,I shall not employ any person in any manner �//� /l SPECIAL Ill.
so as to become subject to the Worker'Com nso'on Laws. ADDRESS,���� / / I✓G. CONDITIONS 0O
Date- 3�d` AID ad CITY ZIP
r I ZIP /z
1.
NOTICE TO APPLICANT: If, aft Maki this Certificate of ENGINEER ARCH`ITECTO vL�` , • / NO.%�� ,! DISTRICT GROUP TYPE FIRE PROCESSED BY O
Exemption, you should become subject to the Workers' , n CONST. ZONE
Compensation provisions of the Labor Code, you must forth- i,(6
with comply with such provisions or this permit shall be- ADDRESS _
deemed revoked. CONTRACTOR G� TEL. /��� STATISTICAL CLASSIFICATION APT. NDO.
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. z DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code., and my license is in full force and effect. CITY CLASS BK L VALIDATION
SQ.FTNO.OF ,� NO.OF nd` CHECK
License Number Lic.Class SIZE STORIES FAMILIES rl�G� ONE
DESCRIPTION OF WORK '/G/ X ,r 7/ r VALU ION 6 2 3 4 A
C tractor Date NEW •w $ � Odv
ADD ❑ # 000023
I am exempt under Sec. I'l/`�/`(1t/ ' ALTER ❑ ,
# a1
B.&P.C. for this reasonf L /. `—�� ❑ $
REPAIR
Date: USE OING BLDG. G' DEMOL ❑ "I x 1 68.95
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT NO. DATE a a 1 6 a 9 5 6
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL 12 3 1 =8 b
Pro essions Code): PRESENT By
BUILDING
I, as owner of the property, ormy employees with ADDRESS
wages as their sole compensation,will do the work and '
the structure is not intended or offered for sale(Section LOCALITY
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- ADDRESS
tion 7044, Business and Professions Code). '
REQUIRED TOTAL SETBACK F M ST..
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 -2726, 1 A
n P.L. # a 0 a 0.0 1
Q Lender's Name LDMA Ref. # 1 - 209,25
P.C.Fee$ Permit Fee
Lender's Address 2 0 9.2 5 C6
@ I certify a a that I have read this application and state that the Issuance Fee Q�• LDMA P/C# '
above information is correct. I agree to comply with all County Investigation Fee �^ 0 6. 1 7-87
ordinances and State laws relating to building construction, Total Fee ;W 9 J LDMA Perm. #
J and reby authorize representatives of this County to enter
3 u o t above-mentioned property f inspection purposes. ,
o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Applicant or Agent Date YYY - O t