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HomeMy Public PortalAbout5933 1/2 PRIMROSE AVE_Building__ \a=te . a e. WORKERS'COMPENSATION DECLARATION 1 - - re affirm that I have a certificate of consent to self APPLICATION FOR BUILDING .PERMIT insusu or re,or a certificate of Workers'Compenstion Insurance,or 7 certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES - BUILDING AND SAFETY _ Policy No. 7-7-9-sq Company P-a a ei,4c J Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS is J 2 %) Certified copy is filed with the county building inspec- BUILDING �/ - G tion department. ADDRESS ;,31Z ! LOCALITY 1NEARET7' Date Applicant CITY ZIP CROSSS T. [�CJi-7. �Wr CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE ( SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars ($100)or less.) TRACT I BLOCK LOT NO. NO. Z—ga),© TEL. SPECIAL- O: I certify that in the performance of the work for which this OWNER ��� NO. CONDITIONS O permit is issued, I shall not employ any person in any manner DISTRICT I GROUP TYPE FIRE PROC E BY' V so as to become subject to the Workers'Compensation Laws. ADDRESST n a3 7 P/ 5 ,08 CONST._ ZONE Date Applicant CITY J (,( ZIP STATISTICAL CLASSIFICATION APT. CONDO. V- NOTIGE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. i S _ LU Exemption,' you should -become subject to the Workers' ENGINEER . NO. CLASS NO.�� DWELL. UNITS Gf IL CO Compensation provisions of the Labor Code, you must forth- Z ADDRESS SEWER MAP Z with comply with such provisions or this permit shall be v deemed revoked. TEL' BK. PG, VALIDATION CONTRACTOR NO. O" G LICENSED CONTRACTORS DECLARATION LIC.. I hereby affirm that I am licensed urider provisions of Chapter 9 ADDRESS — N0.3tjz0 5 VALUATION (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 $1 . (/ 6,f SQ. FT. STORIES F FAJNO.OF CHECK .icense Number ���� LI_.ClassL_ SIZE STORIES � FAMILIES -ONE' adz- NT� �' 1 7 cT z DESCRIPTION F WORK NEW ❑ Contractor d ate- ❑ I am exempt.from the licensing requirements as I am a ADD licensed architect or a registered professional engineer ALTER ❑ FINAL' _ �f -acting in Amy professional capacity (Section 7051, REPAIR EMOL DATE 2 `� Business and Professions Code). USE OF RFINAL EXISTING BLDG. ❑ By �CS- Lic.or Reg.No. Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT BUILDING .I, as owner of the property, or my empldyees with ADDRESS J., as their sole compensation,will do the work and the structure is not-intended or offered for sale(Section LOCALITY z 2 9 9.3 A 7044, Business and Professions Code). MOVING TEL. J I, as owner of the property, am exclusively contracting, CONTRACTOR NO. - 0 0 0 0 0 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). ` 2° 0.7 9.,o�.. REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK• YARD HWY PROP. LINE WIDTH o e o 7 9 Q Q v I hereby affirm that there is a•construction lending agency for FRONT I the performance•of the work-for which this permit is issued P.L. 2 8-8,2 (Sec. 3097, Civ. C.). SIDE P.L. - Lender's Name Lender's Address P.C.-Fee$ Permit Fee � > Q certify that I have read Phis application and state that the Issuance Fee G)a Sd 5bove information is correct. I agree to comply with all County Investigation Fee xdinances and State laws relating to building construction, 9a and hereby authorize re resentatives of this County to enter` Total Fee ipon t above- ent1 a ropert fo spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Age Dote !' ®S