HomeMy Public PortalAbout5714 PRIMROSE AVE_Building__ ftRKERS'COMPENSATION DECLARATION
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I hereaffirmof consent to sf
,'insure, or a certif catte of Worke s'tificate Compensat on Insurance, APPLICATION FOR BUILDING PERMIT c
or a certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS r /Q� !�•
❑ Certified copy is filed with the county building inspec- BUILDING ®��
tion department. ADDRESS S ��/`�+'�
Date Applicant CITY ,.dr Gfffl
` ZIP m LOCALITY C
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CZ CROSS 5T. 4102' O/
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this OWNER ® NOiZJT NO >_
permit is issued, I shall not employ any person in any manner ADDRESS L /p/C/ SPECIAL
so as to become subject to the War Compens t' ws. CONDITIONS u0
CITY G ZIP !�
Date `3 �S Applica ARCHITECT OR TEL. O
NOTIC TO APPLICANT: If, after making s Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY
Exemption, you should become subjec to the Workers' /� CONSTt. / ZONE b
Compensation provisions of the Labor Code, you must forth- ADDRESS �L Q 1� 3IL
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. I ONDO. 2
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. 2 DWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE p4M O STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK ItJ .S A U ❑ $ y`
❑1 am exempt under Sec. .f 01111�
ALTER ❑ 2 2 1.6 A
B.&P.C. for this reason I REPAIR ❑ $
Date: USE OF EXISTING BLDG.41A01 DEMOL ❑ I o 1 1 5 5
EL.
Signature APPLICANT Tt�SSS2. FINAL _ Q
OWNER-BUILDER DECLARATION PRINT N�jf DATE,(/17 ° 1 15505
1 hereby affirm that I am exempt from the Contractor's License ADDRESS ,�� /A1�S6� /'— '
Law for the following reason (Section 7031.5, Business and FINALL5 0']—8 5
Professions Code): PR E BY
BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ,
the structure is not intended or offered for sale(Section LOCALITY
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).
REQUIRED TOTAL SETBACKFROIrM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.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.
v Lender's Name �� LDMA Ref. #
Lender's Address P.C.Fee$ Permit Fee
r I certify that I have read this application and state that the Issuance Fee U c�`� LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee {
ordinances d State laws relating to building construction, Total Fee S 0 LDMA Perm.#
and here uthorize represen t' es of this County to enter
g� upon t abo e-mentioned pr p ty r inspection purposes.
D !6 aY SEE REVERSE FOR EXPLANATORY LANGUAGE O'
Signature of Applica o Agent Dalle