HomeMy Public PortalAbout6035 PRIMROSE AVE_Building__ ' VARKERS'COMPENSATION DECLARATION
hereby.pffirm tha4 I h6ve a'certificate of consent to self [� � � FOR B�B L®I N G PERMIT E RM I T
insure, ar a certificate-of Workers'.Compensation Insurance, [
or a certifie cop t ereof ec. `806, Lab. C.)
.,iy COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Companyl BUILDING /
1:1 •Certified copy is hereby furnished. FOR APPLICANT TO FILL'IN` ADDRESS L7 O�s
❑ Certified copy is filed with the county building inspec- BUILDING L �q�y^L e
tion departmeenyt./ // ADDRESS p®� A
L
Date ���-��.—�OApplicant 92 — Com'! 'd — CITY Cs. ZIP 117 LOCALITY e
CERTIFICATE OF EXEMPTION FROM WORKERS' CP NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT OO NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for oneASSESSOR
hundred dollars ($100)or less.) TRACT �� BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. t USE ZONE MAP I`O�
I certify that in the performance of the work for which this OWNER NO. O41
NO. ✓ y.
permit is issued, I shall not employ any person in any manner �i SPECIAL
so as to become subject to the Workers' ompensation/Law . ADDRESS9715 e e �'V Pft W00 �s p� r CONDITIONS 0O
Date Z`3 Applicant �S •�� .:CITY i �s ZIP / O @S
ARCHITECT OR e g� TEL• DISTRICT GROUP TYPE FIRE PRO ESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of M Q �E/�s NO.
ENGINEER CONST. ZONE
Exemption, you should become subject to the Workers' 0-, �A / _
Compensatin provisions of the Labor Code, you must forth- ADDRESS W► $� lis. 1�
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. NDO.
deemed revoked. ' CONTRACTOR NO. X 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 �; 1)
Professions Code,and my license is in full force and effect. CITY CLASS BK. L PG. /67 VALIDATION
{"may SQ. FT. NO.OF �— NO OF CHECK r.
License Number O Lic.Class y SIZE STORIES FAMILIES ONE F 434,7A
�/ (� / ,�7 VALU TION /)/I d
Contractor i 1 ate C3" '~�/ v DESCRIPTION OF WORK Ap $ �V✓ # 2 3
0 0 0 0
�1 � ❑:;.
❑ I am exempt under Sec. "IT ® �rtl �" ALTER ❑ ( o 61 010
BAP.C. for this reason Vr/ Qi REPAIR ❑:. $
USE OF `' a s 61 Q 1 0 61
D I - EXISTING BLDG. /� �DU�L DEMOL ❑.;
APPLICANT e U TEL. O G,O'1 '86
Signature PRINT / V FINAL _
OWNER-BUILDER DECLARATION NO.�� �!O DATE
I hereby affirm that I am exempt from the Contractor's License � -� ®V� w
amz
Law for the following reason (Section 7031.5, Business and ADDRESS 's FIN
Professions Code): PRESENT By J L'
BUILDING
E]
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 ® 0 6 2 a 0 A
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).
CONSTRUCTION LENDING AGENCY SE7QBACK YARD HWY TOTAPROP. L 11BACK,1f WIDTH
WIDTEXISTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued Pa La
(Sec. 3097, Civ. C.). SIDE
g P.L.
Lender's Name ` b'
� / /� J'` LD"Ref.#
P.C. Fee$ l0!0 6 V Permit Fee 0
Lender's Address
x I certify that I have read this application and state that the Issuance Fee OL LDMA P/C#
¢ above information is correct. I agree to comply with all County .Investigation Fee r L�
ordinances and State laws relating to building construction, Totai Fee 2— LDMA Perm.#
and hereby authorize representatives of this County to enter
$ upon the above entioned property for inspection purposes.
12aC„fv G�1 —3 SEE REVERSE FOR EXPLANATORY LANGUAGE
0 O'
Signature of Applicant or Agent Date