HomeMy Public PortalAbout4933 PERSIMMON AVE_Building__ ' RKERS'COMPENSATION DECLARATION
sure,dpr a cer that I have r certificate of consent to self APPLICATION F R BUILDING PERMIT
insure,�r a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lob. C.) TY OF, O NGELES BUILDING AND SAFETY
Policy No. Company Ob or
Certified copy is hereby furnished. FOR APPLICANT—TO FILL IN BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDINGAA'' A'
tion departt. ADDRESS I ko
ti
Date Applicant CITY ZIP tl LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NOOF�C Q NOW ON LOTS z CROSS ST.
NEAREST
COMPENSATION INSURANCE SIZE OF LOT
(This section need not be completed if the permit is for one ASSESSOR
TRACT BLOCK LOT NO. MAP BOOK PAGE
hundred dollars($100)or less.) PARCEL
y
OWNER
TELUS
3
. �NE MAP
I certify that in the performance of the work for which this NO. / NO.
permit is issued,I shall not employ any person in any manner 1 fie''11 ' SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS Z✓3 ItV Q CONDITIONS C�
-nt (.- ZIP J Do
Date �� Applicant �y Ib 51 1y ARCH ITECT OR TEL. 0
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP CONST. ZONE PROCESSED BY O�
Exemption, you should become subject to the Workers' 5- 4. / 3 C�
Compensation provisions of the Labor Code, you must forth ADDRESS .l, V W
with comply with such provisions or this permit shall be
dCneemed revoked. TEL STATISTICAL CLASSI�FIATION APT. NDO.CO
CONTRACTOR NO. CLASS NO.. ILL—DWELL. UNITS
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ.FT. NO.PF NO.OF CHECK
License Number Lic.Class SIZE STO IES FAMILIES E
VALUATION
Contractor Date DESCRIPTION OF WORK NEW
D ❑* $
I am exempt under Sec. WW MS ALTER110,
❑ p
t I�� ❑. �89a9A
B.BP.C. for this reason RKAL/ -WIPAR u 2 REPAIR $
OSE OF *n 0 0 0 0 0
Date: EXISTING BLDG. �� �i L�yRy DEMOL # 1
APPLICANT TEL. I o 0 2 8,5 0
Signature NO �, FINAL O
OWNER-BUILDER DECLARATION PRINT LJ 1 >: DATE My
I hereby affirm that I am exempt from the Contractor's License ADDRESS 8J .5 IU •�• FINAL o 0 o 2$5 0 mu
Law for the following reason (Section 7031.5, Business and
Prof ssions Code): PRE NT BY N 0203-88
( BUILDING
LI I, as owner of the property, ormy employees with ADDRESS
wages as their sole compensation,will do the work and LOCALITY
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). MOVING TEL.
I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
SETONO
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name LDMA LRef. #P.C.Fee$ Permit Fee rov
Lender's Address
I certify that I have read this application and state that the Issuance Fee LDMAabove information is correct. I agree to comply with all County Investigation Feeordinances and State laws relating to building construction, Total FeeLDMA
3 and hereby authorize representatives of this County to enter
o upon t bove-mentioned prrty for inspection purposes.
g
o "Ov SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant Jr Went Date