HomeMy Public PortalAbout5532 PARMERTON AVE_Building_12/4/1989_family, powder, master bdrm "n WORKERS COMPENS?TION DECLARATION _ r
insure
affirm that 1liaW r Camficate of consent to self , v APPLICATION-FOR- BUIL DJNG PERMIT
ora c ore certificate a Workers Compensation Insurance, •- 1 I - r
or a certified copy thereof (Sec 3800 Lab C )_ - I J, COUNTY OF LOS ANGELES'- " ^• " BUILDING AND SAFETY
• Policy No S' ' Company a.• 1 - I •, a 5
BUILDING /�'Jz �W5:1ZTm e-
50 Cerhhed copy'is hereby furnished �- �y FOR APPLICANT TO FILL IN . ADDRESS O� J r+"rTv,'C"El1 V a ,
❑,._Certified copy is filed with the county building inspec- - gDDRE55 Ss 2 1'FIeT - P/Q` C r T,� s p/-�
` tion,deportment - _ - 7
•Date - S w Applicant CITY F + CIT'P ZIP N7po LOCALITY "e/wP�e i✓' ( + _
,NO OF BLDGS _
+ •"'`
"'CERTIFICATE OF EXEMPTION FROM WORKERS N,. SIZE OF CLOT O X/ NOW ON LOT 4,7- - CN.R�OSSSST r}1 /U e S - -
cI 'COMPENSATION INSURANCE �, ASSESSOR ,} ,
•(This section need not be completed if the permit is for one TRACT BKLOCLOT
/. 'DIS_7R�� GA)17
UP OPTTV ' ZONE D BY O
Exemption 'you should,become subject to the Workers • 5.
Compensation provisions of the Labor Code, you must forth ADDRESS _
,Compensation
with such provisions or this permausholl be " ' r " -TEL STATISTICAL CLASSIFICATION _ -APT CONDO 'n
deemed revoked CONTRACTOR 0�41NeQ NO _ _ /y / I z
a , LICENSED CONTRACTORS DECLARATION . � � LIC CUSS NO DWELL UNITS_ _
I hereby affirm that I am licensed under provisions of,Chapter 9 ADDRESS NO _ SEWER MAP . iC
(commencing with Section 70DO)of Division 3 of the Busineu LIC /.,
and Professions Code and my license is in full force and effect CITY. CLASS BK PG `/� „T _'7 VALIDATION
r-` SO FT• NO OF NO OF CHECK
LicenseJNumber -ill v 1bc Clais - s SIZE STORIES FAMILIES ONE" VAl A ON '[i� 1 All I •T s • t +
DESCRIPTION OF WORK NEW ❑ J( � ^j(7 l
Contrador Dote _
ADD-
0 $ V JJ_ 'jO�L yLI
w - -
I am exempt under Sec - ALTER t _ - i -
^ a - ❑ ,• 1-ITEM
' B&P C for this reason - - T /SWr S .r. _ �' _r TOTAL 3170,. 570
REPAIR ❑
_ Date ' 'c E%ISTNG BLDG ' /''7ls - ' -.•- oEA+a❑+ CHECK J313.90
- - ,
TEL. o.fZ1 FINAL CHANGE
RA (PRINT) NOSignature APPLICANT1% t
OWNER-BUILDER DECLADATE .CUL
Z -
I herebyaffirm that,l am exempt from the Contractor s License - - - • - - ,
ADDRESS FINAL IVOO-0001 ~ 7
Low fothe following reason(Section 7031 5 Busmen and E}A/�Q�A) � '� r
Professions Code) ` RESENT • - ^ '"r"^ �' By L , �� /:�
' $ BUILDING ~- `T
as owner of the property, or my employees with ADDRESS 7+ 1 AN 10:*7
wages as their sole compensation WJI do the work and - _ Pool h , `�•( v + i t
the structure isnot intended or offered for sale(Section LOCALITY v � 1
,w 7044 Busmess and Professions Code ) L , ' MOVING •^ - — TEL ^.� -
❑ I as owner of the property am exclusively contracting CONTRACTOR - 1 NO
with licensed contractors'to construct the project (Sec - ADDRESS -'- -` , r� �TT� ��' 2,•(( + r
hon 7044, Business and Professions Code ) I �•' �+' I+, +� 0 r, (� _" ' ,
_.5. REQUIRED YAC FIN,y' _ TOTAL SETBACK FROM,' EXIST
•I {, CONSTRUCTION LENDING AGENCY SET BACK P UNE WIDTH+
I hereby affirm that there is a construction lending agency for FRONT _ _ - - �,�.,•} +MS- � �`' S ( - �+�- •
s , 'the performance of the work,for which this permit is issued PL- - i• 'LL i • T
(Sec 3097 Civ C ) _ SIDE . • ^ - r
-Lenders NameAW- ` nR6'f- A'6` { . •�, y
< Fee S Permit Fee 36 Z`2 t--i ♦ r t
Lender s Address - - - ._ M ... - 7 '
c -1 certify that have read this apphcahon and statethat the,,, ' •i Iuaance Fee / O 7 1 CDMA P N i 'i , • '
oboveimformation is correct I agree to comply with all County Investigation Fee
ordinances and Stbte laws relating to building construction Tola1 Fee
and hereby authorize representatives of this
u on t bon enc acted p for inspection - -
C ,/// `
Pee //p it SEE REVERSE FOR EXPLANATORY LANGUAGE . \ + r TynL :�T
Signature of Applicant or Agent l Dote i ( -I —_-
p X791