HomeMy Public PortalAbout9046 RANCHO REAL RD_Building_1987-07-29 WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self ; APPLICATION
® ®P L I C 6��l [� I R BUILDING 1
4
insure, or a certificate of Workers'Compensation Insurance, �'®li Lt
or a certified copy th reof(Sec. 3800, La .C.) �. COUNTY OF LOS ANGELES BUILDING AND SA TY
1r Inc
Policy Nd _Compan
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING /
ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS /� //�
Date t / Applicant CITY C ZIP /"/190
LOCALITY
CERTIFICATE OF EXEMPTION FROM WKERS' NO.OF BLDGS. NEAREST
COMPENSATION INSURANC • SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the ermit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. US ONE MAP
I certify that in the performance of the work for which this OWNER ��//// ` e NO. /Jf��`/ NO.
permit is issued, I shall not employ any person in any manner ADDRESS ®75P C e B SPECIAL
so as to become subject to the Workers Compensation Laws. CONDITIONS 8fO
9)"
�/� U
Date Applicant CITY 1 ZIP /) 0 X
ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PRO SED BY
NOTICE TO APPLICANT: If, after making'this Certificate of ENGINEER NO. � n CONST, 1 ZONE
Exemption, you should become subject to the Workers' 1V/ U
Compensation provisions of the Labor Code, you must forth- ADDRESS W
with comply with such provisions or this permit shall be •gg��t'�,�\
deemed revoked. CONTRACTORS-W W NO CrOJ °:STATISTICAL CLASSI�FICATION APT. CO
LICENSED CONTRACTORS DECLARATION LIC,��/�Q CLASS NO. (/ DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �� S NO.�%ZOO�
(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
License Numbe �WB �'� SQ. FT. STONO. IE NO.OF CHE K
Lic.Class SIZE STORIES FAMILIES ONE
�`�'��p VALUATION
Contracto kl�eDate T DESCRIPTION OF WORK mb NEW ❑ $ `ON 00
+ ADD ❑,. `
❑I am exempt under Sec. m �a,
ALTER ❑.;
B.BP.C. for this reason i REPAIR ❑ $
USE OF
Date' EXISTING BLDG. DEMOL ❑
APPLICANT TEL.
Signature FINAL
OWNER-BUILDER DECLARATION PRINT NO. DATE /
I hereby affirm that I am exempt from the Contractor's License ADDRESS FINA ;27554A
\ Low for the following reason (Section 7031.5, Business and
Professions Code): PRESENT Sly # 0 0 0 0 0
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS .o - 49.88
wages as their sole compensation,will do the work and y
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. /_✓ 0 0 - 49, 88'0
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO.
(� 7'
• with licensed contractors to construct the project (Sec- ADDRESS 4 � � � 7.29-87
tion 7044, Business and Professions Code).
REQUIRED YARD HWY TOTAL SETBACK
CONSTRUCTION LENDING AGENCY SET BACK PROP.LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performapce of the work for which this permit is issued P.L.
(Sec. 3097,Civ. C.). SIDE
P.L.
Lender's Name
of \
\ P.C.Fee$ Permit Fee LDMA Ref. #
nder's Address `
I'certify that I have read this application and state that the Issuance Fee J� LDAAA P/C a
c above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. N
9 and hereby authorize representatives of this County to enter
9 upon} 3 abode-menti ed roperty for inspection purposes.
i
SEE REVERSE FOR EXPLANATORY LANGUAGE
1 Signatur of Applicant or Agent Date