HomeMy Public PortalAbout9030 PENTLAND ST_Building__ WORKERS COMPENSATION DECLARATION
hereby effgmYhat I.have certificate of consentto ,elf APP �MC TION FOR` BUI_LDING - PERMIT
� insure, or a certificate of WarWorkers' Compensation Insurance •- - - �
, *'or Acertifie�d�,co��p��99y ptth��e�rreof (Sec 3800, Lab C ) ' COUNTY OF LOSvANGELES' j 'BUILDING AND SAFETY '}
licy No/2-); t;(7-Ccmpany.s/7'¢r��C'VA/0 '{ ,
❑e Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS ' / 3� /�/ L /✓O .
BUILDING
.❑ `
Certified copy is filedrwnh the county building inspec- - s "" -
,vtion deportment t T ADD�SS 9� /r `
TUA✓ �ni1tTG/2e/ld CI Y. E zl`r 9 D LOCALITY C tT C/T% C -
'Data9 i�-�ZApPbcant^+
CERTIFICATE'OF EXEMPTION FROM WORKERS' F- - ` NO OF&D'S NEAREST' - -
'T SIZE Of LOT �( `NOW ON LOT •Z CRO55 ST
COMPENSATION INSURANCE - ASSESSOR
(This section need not be completed If,the permit is for one ^ TRACT- Z BLOCK LOT NO i MAP BOOK � J - PAGE �`� PARCEL `
t hundred dollars IS 00) or less ) ` TEL SE ZONE MAP
• ' • • r OWNER -L-0eQ S) - S '
9 N
I cert6that in the,performance oftthe work for which this, v t
permit a mued I shall not employ any person in any manner- �-- ADDRESS - _ SPECIAL
'L ti 4 CONDRIONS^
•so as to become subject to the Workers CompensationtLaws O
J• ..� • ) i'iS . -A e- CIN ZIP J- •� r u
Date Applicant „ , ARCHITECT OR TEL
\ < DISTRICT. GROUP TYPE FIRE y - O
NOTICE LTO APPLICANT If'cher making this'Cenificate of----- ENGINEERS•. -q - - NO-- •"- •- CONST' ZONE rr
Exemption„ you, should become subject to the Workers y.. - �^ Q V'
Compensation provisions of the labor Code you must forth- - ADDRESS <•�O K d
with comply with such provisions or this permit shall be TEL - STATISTICAL CLASSIFICATION _APT CO
n� Z
• deemed revoked �, - „1 +, CONTRACTORM1 lJe q/OVO 31r . + • }
LICENSED CONTRACTORS DECLARATION r ' LIC r CLASS NO DWELL'UNITS
^I hereby affirm that I am licensed under provisions of Chapter9 ADDRE55� NO s. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC
+and Professions Code,and my license is m full force and effect CITY -�'� —� BK PG VALIDATION
SO FT NO OF NO OF CHECK `
License Numbe :LSO Lic Class -'� V SIZE - STORIES FAMILIES ONE i
+ + 1 -�" - — - • VALUATION s
s DESCRIPTION OF WORK i ` NEW ❑' ` B�-
Conrracton�Ir7'✓ lsrl/E.I.2ls7•ifr'te �/7—/� j -
�. - ADD ►
❑I am exempt under Sec ^ U
.ALTER ❑ i
i + B BP C for this reason +�% Y- .... w REPAIR ❑ '$ d' i I
USE OF , _
'Date EXISTING BLDG ~ S D a DEMOL O
Signature '4' 7(PR('AINT JLJ _ s / E NO FINAL `
WNER-BUILD DECLARATION
hereby off m that I am ex pt fiom the Contractor s License `- „s• }- s , DATE T'
c ADDRESS •Y SIJ C3LL � `Sr• C.-1J s
Laereb the following reason (Section e C 5 Business and FINAL
Professions Code) I - . PRESENT M - _ ( '—. - i__ -BT_ 7307
BUILDING
❑ as owner of the property, or my employees with ADDRESS
wages as their sole compensation will do the work and " • .y .- " ` - -4!/ �l `1
the structure is not intended ogoffered for sole(Section LOCALITY •} *- a-- , y� .�+f �tY1- i 'r `
7044 Business and Profession Code ) - MOVING
•• -^ ' TEL
❑ I as owner`of the property, am exclusively contracting CONTRACTOR NO s• -r 72137 :j,',�5
_
I with licensed contractors to construct the project (Sec' ' '" -. - • '' e I EM7
hon 7044, Business and Professions$Code ) ADDRESS - „� Ix^" s� �s i
REQUIRED - ' "T TOTAL SETBACK FROM' ' EXIST"" �" " 1 s +•}{]
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP LINE WI b t - 'T "l l!iAL' „ 237 _ 44
hereby affirm that there is o construction landing agency for ,`+ FRON7 ,x _ _ „" b i ' nO-t
the performance of the work for which this permit is issued - PL ( .��
(Sec 3097 Civ C ) - SIDE
r•` _ .-.. _,. FPL
Lenders Name
LDMA Ref R
PC Fee
$
Permn Fee JIJ IL) 0001 }�IS1
Lender s Address ^ F I f
a Ice%ify that I have read this apphcahon and state that the Issuance Fee LDMA P/C R ► cre1 } p� r.c_
8+ above information is correct I agree to comply with all County Investigation Fee - - -
R rdinancestund State laws relating to building construction, Total Fee. 'LDMA Perm R
a her4n.lAppl,cM
Or.
epresentahves of this County -
"up n thet ned property far mapection purposes '•` - r
gZ_ s SEE REVERSE FOR EXPLANATORY LANGUAGE
Sir Agent Date
- ,Y