HomeMy Public PortalAbout6031 PRIMROSE AVE_Building__ I! if . t. \
WORKERSCOMPENSATION DECLARATION
I hereb' '�ffi;ri that I Brave a,.certificote of consent to self
insur'e,; r�arcertificate of �ark'ers'Compensation Insurance, APPLICATION F R BUILDING PERMIT
or a certified co y hereof(See. 3400, Lab. C.)
t COUNTY OF LOS ANGEL BUILDING AND SAFETY
Policy No. Z ompany�Il1� - 'Q - s�L1� 112
ILDING ` J� 1
❑• Certified copy is hereby furnished. FOR APPLICANT TO FILL INDDRESS 46d5
❑ Certified copy is filed with the count building inspec- BUILDING A,� ��tion department. �� ADDRESS 0� M pplicant d)d4i�'ISaek-L- CITY r ZIPCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' p- NO.OF BLDGS. AREST
COMPENSATION INSURANCE SIZE OF LOT O O O NOW ON LOT � OSS ST.
(This section need not be completed if the permit is for one SESSOR-hundred dollars($100)or less.) TRACT BLOCK LOT NO. AP BOOKPAGE PARCEL
TEL. E ZONE MAPQI certify that in the performance of the work for which this OWNER I o U NO 17r,1_ SPECIALpermit is issued,I shall not employ any person in any manner IL
ADDRESS 13 C-1 V� boP •— CONDITIONSso as to become subject fo the Workers'Compensation Laws. O
V
CITY C_ ZIP 7 g5Date Applicant ARCHITECT O �AA B, �r. TEL• DISTRICT GROUP TYPE FIRE PR E D BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER (dl v s�� NO. CONST. ZONE
Exemption, you should become subject to the Workers' /� /� b
Compensation provisions of the Labor Code, you must forth- ADDRESS S��0 �� t/ 9L
with comply with such provisions or this permit shall be EL. STATISTICAL C SS ION APT. I CO DO.
deemed revoked. CONTRACTOR NO. 1,
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS f
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 /A 7 VALIDATION
SIZE STORIES F 7�• NO.OF B CHECK
ONE
License Number Lic.Class_L VALUATION �4 3 4 4 A
I - Date ..—fJ DESCRIPTION Of WORK NEW $ g 7 ,sUd 0 0 0 0
Contractor D TOWN
O ADD ❑� ✓ 2 3
I am exempt under Sec. WN ALTER
❑ 1 o 6 1 Q 1 0
B.BP.C. for this reason U� s+7• alwf e, REPAIR $
Date "
O
USE OF �pJ '1 + DEMOL [_1o 0 6 1 0, 1 0 6
EXISTING BLDG. 1� �G
Signaturelkr. �� - APPL(PRINT) p TEL. FINAL ,� Q U. 0 1 —8-6
OWNER-BUILDER DECLARATION NO. DATE
1 hereby affirm that I am exempt from the Contractor's License 5 li /.A 0•Ve
Law for the following reason (Section 7031.5, Business and ADDRESS r " SIR
FI� L
Professions Code): PRESENT B
❑ BUILDING
I, as owner of the property, or myemployees 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 SETBACK FROM EXIST.
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 7 r
P.L.
Q Lender's Name
$ q J� �! LDMA Ref. # 7` c o
Lender's Address P.C. Fee$ (J / Permit Fee /
> S. 5
I certify that I have read this application and state that the Issuance Fee �r�• LDMA P/C# ' I o `�i
a above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, T ' " t 5'
otal Fee �Qp'�� LDMA Perm.# `' 8 `" 5
u and hereby authorize representatives of this County to enter ,
9 upon the above entioned propertyforinspection purposes. i P. 1 _' O
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date O t