HomeMy Public PortalAbout5947-5947 1/2 PRIMROSE AVE_Building__ c aRKERS'COMPENSATION DECLARATION
rm
ac�ti ' a h ce•� a of consent to self
dctilir. ferto 'Workers' Compensation Insurance,
APPLICATION F®R BUILDING PERMIT
ertifiopy
thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
F-1 !!
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING -9'- -7
ADDRESS
Certified copy is filed with the county building inspec- BUILDING /'
F1
tion department. ADDRESS % 70�( ��^`-��5'L' A
^r— �
Date Applicant CITY .ZZIP /79,d LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' �j NO. F BLDGS. NEAREST
cbMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. .�
(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
OWNER �'vQ«�'\ NO. Z15�0 7°I7 USE ZONE MAF
I certify that in the performance of the work for which this �
s permit is issued, I shall not employ any person in any manner t, S - SPECIAL
so as to become subject to the Work o�nsat!!CLaws_ ADDRESS t l N �� ///` CONDITIONS U CITY 'L v- i� C l� 'zip �/? (�
Date Applicant
tw NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
O� �CS �
Exemption, you should become subject to the Workers' ENGINEER �" C=J NO. CONST. ZONE I-
-� � V
Compensation provisions of the Labor Code, you must forth- ADDRESS i� a
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. I CO DO. U)
deemed revoked. CONTRACTOR S Z-L 4- , ` ����NO. i/L�� ®—��,
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
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 L- PG VALIDATION
SQ. FT. �0�J NO.OF NO.OF CHECK
License Number Lic.Class SIZE / STORIES Z FAMILIES Z-- ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW
D $ C/� q�0
❑ ALTER I am exempt under Sec. �� G, L �p lZI ���a�pc ❑ (
B.BP.C. for this reason '3`�Sa1�„- �•i6T � REPAIR ❑ $ --7876'9A
Date: USE OF
EXISTING BLDG. �'�'' L't /—�'—s L DEMOL ❑ 0 0 0 o L 3
WW
Signature APPLICANT TEL. FINAL
PRINT vim' '!T{4( NO. ZS�c- 7 /( 70 1 - 67a95
OWNER-BUILDER DECLARATION DATE � /
I hereby affirm that I am exempt from the Contractor's License c' `
Law for the following reason (Section 7031.5, Business and ADDRESS S 7�S i♦ r r r ' �a `p^�� Ch FIN 0 0 6 7 8 9 53:
Professions Code): BUILDING � c % B
❑ S`�K S 1! << w 2 0� ce C,T 0 1, 1 3 -88
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and n I ;
the structure is not intended or offered for sale(Section LOCALITY G� t� ` L
7044, Business and Professions Code). MOVING �qq _In� TEL.
I, as owner of the property,am exclusively contracting CONTRACTOR A) "� NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROPAL LICK NE WIDTH
I hereby affirm that there is a construction lending agency for FRONT f
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE r
P.L.
Lender's Name ,
LD Ref. ff'. I - 795.75
P.C.Fee$ L ) Permit fee r
Lender's Address ° ° 7 9 5.�) 5 CF-
I certify that I have read this application and state that the Issuance Fee O 1 (� LDMA P/C c_
@ above information is correct. I agree to comply with all County Investigation Fee
9 ordinances and State laws relating to building construction, Total Fee S S LDMq perm.a V
N and hereby r
orize representatives of this County to enter
upon he ab �entioned pr rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applican r gent Date