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HomeMy Public PortalAbout5337 PAL MAL AVE_Building__ 0 WORKERS COMf'`NSATION DECLARATION. y hereby affirm that I have 6 certificate ompa of cement to self APPLICAtION FO�PILDING PERMIT Insure or a certificate of Workers Compenstion Insurance or a Policy Ned copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGEL BUILDING AND SAFETY Polity No Company 1 U Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESSSS Certified copy Is filed with the county building InspecBUILDItNG tion department ADDRESS LOCALITY p NEAREST Date Applicant CITY ZIP CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS J NO OF BLDGS ASSESSOR COMPENSATION INSURANCE SIZE O LOT L9 ps/ NOW ON LOT MAP BOOK PAGE PARCEL •i (This section need not be completed If the permit is for one - U MAP 4 TRACT BLOCK LOT NO NO hundred dollars ($I00)or less ) TEL SPECIAL Lt d I certify that in the performance of the work for which this OWNER /Y1 N /Unq CONDITIONS O permit Is issued I shall not employ an person in an monner / DISTRICT GROUP TOPE FIRE V p p y y� y DDRE55 L. L �© CONST ZON (65 so as to become subject to the Wor rs Compensation Laws , / ' v KDate/a�Applicant TV L ZIP RCHITECT TEL STATISTICAL CLASSIFjG4TION CONDO NOTICE TO APPLICANT If oh a ing this Certificate of W Exemption you should beco subject to the Workers ENGINEER NO CLASB NO DWELL UNITS_ d Compensation provisions of th abor Code, you must forth ADDRESS SEWER P ? with comply with such provisions or this permit shall be TEL 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 (commencing with Section 7000)of Division 3 of the Business and p/ LIC Professions Cade and m license is in full force and effect CITY CLASS $ Y 92619' SQ FT tN0 O NO OF CHECK License Number LIC Class SIZE STORIES FAMILIES ONE S Contractor Date DESCRIPTION OF WORK /Y NEW ❑ [v 4/ `" I am exempt from the licensing requirement as I am a C' 725 �6 ADD licensed architect or o registered Professional engineer K� ALTER C] FINAL .f J r2 2 1 3 1 A acting In my professional capacity (Section 7051 (� /✓ /•�� N REPAIR ❑ DATE i Business and Professions # • • • • 23 ons Code) USE OF / FINAL EXISTING BLDG /7s DEMO ❑ FI Q • 2600 LIC or Reg No Date APPLICANT LEIn/ O PRINTI /C OWNER-BUILDER DECLARATION r �3t., • • 1 2 6 0 0 csi I hereby affirm that I am exempt from the Contractor s License ADDRESS' L AG Low for the following reason (Section 7031 5 Business and 12 01 -81 Professions Code) BUILDING I as owner of the properly or my employees with ADDRESS wages as their sole compensation well do the work and -7. the structure is not intended or offered for sole(Section LOCALITY O / ;9 2 1 3 2 A 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 (Sac ADDRESS 2 • 4 3750 hon 7044 Business and Professions Code) REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP UNE WIDTH • • 4 3 7 5 0 v I hereby that there is a construction lending agency for FRONT .� the performance3097Cof the work for which this perms ro issued - P L ) 2 0 1 8 (Sec 3097 Civ C ) SIDE PL Lender s Name / rPC�s K%T h g P C Fee Permit Fee ssC _ Lenders Address > I canny that I have read this application and stab that theIssuance Fee ! above information is correct I agree to comply with all County Investrga ion Fee - 888 ordinances and State jaws relating to budding construction Tolaj Fee Sd and hereby authorize representatives of this County to enter W on the above-mentioned pr party for inspection purposes i(�` / SEE REVERSE FOR EXPLANATORY LANGUAGE r S,gnoture of APPbmn,or Agent Dole ®F