HomeMy Public PortalAbout5233 PAL MAL AVE_Building__ WOR�(M'COMPENSATION DECLARATION
?M:9 v a#ce tificate have a of Workers'certificate ensaconsent urance, APPLICATION FOR BUILDING PERMIT
µorad certi4ed copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY /
PlicyNo!`�❑o 't+"` Company • I
Certified copy is hereby furnished. I; FOR APPLICANT TO FILL,IN ?. BUILDING
ADDRESS 1 maL
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS CL mea LOCALITY Te
NEAREST
Date Applicant CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. 'ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT 1 W .Y NOW ON LOT P BOOK PAGE PARCEL
(This section need not be completed if the permit is for one < USE ZONE MAP
hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO.
TEL. r,f SPECIAL 9.
I certify that in the performance of the work for which this OWNER w NO. $- CONDITIONS 0.
permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY O
so as to become subject to the Wor era'Compensation Laws. ADDRESS CONST. ZONE ld .
29
•}Ir; D CITY P ZIP ( b ` ca `'`� O
Date d Applicarit STATISTICAL.0 IFICATION CONDO.
J_-NOTI E T APPLICANT: If, after making this Certificate of ARCHITECT O TEL.
Exemption, you should become subject to the Workers'' ENGINEER NO. CLASS NO. 2,1 DWELL.UNITS IL
Compensation provisions of the Labor Code, you must forth- ADDRESS, SEWER MAP U)
with comply with such provisions or.this permit shall be
deemed revoked. CONTRACTOR . NO. BK/ PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed.under provisions of Chapter 9 ADDRESS NO. VALUATION
1 (commencing with Section 7000)of Divislo.A 3 of the Business and LIC.
Professions Code,'and my license is in full force and effect. CITY CLASS $
SQ.FT. NO.OF' NO.OF CHECK
License Number' Lic.Class SIZE STORIES FAMILIES ONE , G 9. A
,� - - - --NEW $ �� 6 •-
Contractor Date �� DESCRIPTION OF WORK ADD a o o 7j
I am exempt under Sec. c? 0 2
ALTER �:. FINAL 5
B.BP.C. for this reason \ REPAIR DATE �, a'a L b 5 r- r
USE OF
Date:
EXI571NG BLDG. DEMOL- N -117-0 5— (�
Signature APPLICANT TEL.
OWNER-BUILDER DECLARATION, PRINT NO.
I hereby affirm that I am exempt from the Contractor's License ADDRESS `
Low for the following reason (Section 7031.5, Business and , : 360.�A
Professions Code): ll�PRESET it o o a o L_
❑ BUILDING
I, as owner of the property, or.my employees with -ADDRESS Z o o 5
wages as their sole compensation,will-do the work and
the structure is not intended or offered for sale(Section LOCALITY a a o `' (! X
7044, Business and Professions Code). MOVING TEL.
I,as owner of the-property,am exclusively contracting CONTRACTOR NO. C_ )0'--F (I
with licensed contractors to construct the project (Sec- ADDRESS . 'f /
tion 7044, Business and Professions Code). 0." A
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST: n e n o o 1
SET BACK PROP. LIN WIDTH.
I hereby affirm that there is a construction lending agency'for FRONT 2 a _ - r; 0
the performance of-the,work for which this permit.is issued P.L.
tSec. 3097,,.Civ. C.). BIDE. �',
a Lender's.Name •: �'_n
a
P.C.Fee$' Permif F e %i•,
Lender's Address
r I certify that I have read this application and state,that the s Issuance Fee j�o
above information,is correct. I agree to comply with.all County Investigation Fee ",• •,
3 ordinances and State laws relating to building construction, Total Fee �. �Q T .1 ,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE '
V im- � h&w '.E'�;nivt%�io�;s� ?J, 0 8
/� Signature of Appli�can or Agent to ®s
t