HomeMy Public PortalAbout9034 PENTLAND ST_Building__ WORKERS COMPENSATION DECLARATION t . • w7
hereby affirm that I have r ae,Come of tion Insurance,
self APPLICATION FOR BUILDING PERMIT
insure or a certificate of Workers.Compensahon Insurance, • +t;
or a certified copy thereof (Sec 3800, Lab C ) -
V, ' „ S� ' " -1 • _ -" _ COUNTY OF LOS ANGELES ' F'-- - BUILDING AND SAFETY
Policy No T)Lk0!A1 ( Compony TQ�ci.tea
®
a BUILDING Jn� _ �� sl/-�Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS C/ •
Certified copy is filed with the county budding Inspec- DDREu -
hon department, i ,
•• r ,` } _^ CITY A ZIP - ~
Date�T Apphca } ^� LOCALITY
OF„BL S NEAREST- .-
•'� CERTIFICATE OF EXEMPTIOWORKERS SIZE OF LOT NOW ON LOT CROSS S7
Id tt• •'COMPENSATION INSU NCE t • T - •- a ASSESSOR, �• '
(This section°need not be completed if"the permit is for one' TRACT BLOC; LOT NO MAP BOOI(`-� PAGE PARCEL
hundred dollars ($100)or less ) TEL
OWNER ri" No
NO - USE ZONE MAP /•/ ,
I certify thatun�the performance of the work for which this T O SPECIAL 77 - }.
` t)permit is issued, I shall not employ-any person in any manner ADDRESS a3 - /\ � CONDITIONS ! >-
Pso asdo become subject to the Workers Compensation Laws _ _ _ ,-„ _ • „ O `
•' i " - CITY g IP O - - V
DatCE,
Apphcar ��-/�/,^ ���'-� ARCHITECT OR- T L ^ O
NOWT,CE•TO APPLICANT, If,'after this Certificate of � ENGINEER ,� - DISTRICT- GROUP, TYPE FIRE SSED BY
Exem tion, you should• ' - ^ CON31 1ST/' L3NE j
t p y became subject to the,Workers- 0 ✓
Compensation provisions of the labor Code, you must forth- ADDRESS _ _ _ - d
with comply with such provisions •or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO Z
deemed revoked y CONTRACTO NO y _
' , LICENSED CONTRACTORS DECLARATION, LIC CLASS NO I DWELL UNITS
IT
` I hereby off irm that Liam licensed under provisions of Chapter 9 ADDRESS is, NO
(commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP t E• a" ^ a
and Professions Code,and my license is in full force and effect CIN �`u BK PG I VALIDATION ..
SQ FT OF NO Of ECK
License Numbed—iV?f Lrc Class SIZE STORIES FAMILIES ONE
P.' /"' /•7 nn 1 "- - VALUATION
ContractorilLj/ �oOT•fTate�^�f�Q / I NEW
DESCRIPTION OF WORK _ ADD ❑ �, S�c„j y `I •oar ,, - _ r.
❑I am exempt under Sec 12 ❑ _ ►
ALTER
r B 8P C,for,thisreason * �' REPAIR ❑ f t
USE OF_ ,. -• - ! ,
' Dat EXISTING Ei • P DEMOL ❑
S,gnnn,rAPPLICANT TEL - ' -FINAL
^ P+ O �1 ' UJ DECLARATION I (PRINT) NO DATE - I X
hereby affirm ilio am 4e mpt from the Contractor's License
-` Law for the following reason (Section 7031'5`Busmess'and ADDRESS ' i i FINAL _ 4
Professions Code) _ PRESENT - - -- . -- BTr - •e r s
BUILDING AI C r t
El 1, as owner of the property or my employees with ADDRESS n� t .r _ f'
- wa es os their sole compensation,will do the work and . -• - - -E _ '7
thestructure is not intended or offered for sole(Section LOCALITY I i =_I!,t
.^ ❑ 7044, Business and Professions Code ) .. MOVING- TEL - - • ,• { L 2lT ll
� i ,
I as owner of the property, am exclusively contracting CONTRACTOR NO y
with licensed contractors to construct the project (Sec- -- - - - ' "s (LI l Q[. 3--- 00
' hon 7044, Business and Professions Code ) ADDRESS LI�
CONSTRUCTION LENDING AGENCY
REQUIRED YARD HWY TOTAL SETBACK
ETBPROPA K FROM WIIS Ht �r -• •'`` - Y CTi_C Yv - - - •r•.�..,II I
I hereby affirm that there iso construction lending agency for FRONT I-}{�r � ` _ •,1]IJ
•the performance of the work for which this permit is issued PL -
(Sec 3097 Civ C ) i ' SIDE i .T-'n fu ❑ '
~Lender's Noma` _- `t•-• ,-• P L ,
-LOMA Ref 11
Lender s Address y
- P C Fees Permit Y
Fee '+i( ' -,1 , it'll 7:51
c
certify that"I have iea'd this ajiplication and state that the t Issuance Fee /,3, LDMA PTC p r < polo
'above information is correct_I agree to comply with all County Invesngavon Fee ^ qq
-ordinances and State jaws reloting•to building construction, •Total Fee 4`~a� LDMA Perm It
Q and hereby authorize representatives of this County to enter
R$9 -upon the above-mentioned property for irispection purposes �" i •r -4
SEE REVERSE FOR EXPLANATORY LANGUAGE�� _ fig
n -
- Signature of Applicant or Agent Date