HomeMy Public PortalAbout5815-5817 RENO AVE_Building__ WORKERS' COMPENSATION DECLARATION el
I hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T
Insure, or a certificate of Workers'Compensation Insurance, '
or cxtif! o thereof(Sec.'38 Lab. C.) f COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policyvv�jN CompanBUILDy I e
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Certified copy is hereby furnished. d— _�3 FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS — 6% ��0�
Date. Applicant '^' CITY ZIP 9 3 0 LOCALITY G
NO.OF BLDGS. NEAREST
CER FICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACTBLOCK LOT NO. MAP BOOK PAGE PARCEL
11
hundred dollars($100)or less.) T
OWNER N f NO (e..p1f3 USE ZONE MAP
I certify that in the performance'of the work for which thisSPE
permit is issued,I shall not employ any person in any manner ADDRESS � SPECIAL a
CONDITIONS
so as to become subject to the Workers'Compe sationLaws. �+ O
. }- CITY Q / ZIP FZ
Date Applicant ARCHITECT OR' TEL.
i DISTRICT GROUP TYPE FIRE PROCESSED BY 10
NOTI T APPLICANT. If, after making this Certificate of ENGINEER NO. nn CONST'./ ZONE
Exemption, you should become subject to the Workers' I
Compensation provisions of the Labor Code, you must forth- I ADDRESS
with comply with such provisions or this permit shall be TEL.7 STATISTICAL CLASSIFICATION APT. CONDO, to
Z
deemed revoked. CONTRACTOR 21b A fig Wra NO. 3 -
LICENSED CONTRACTORS DECLARATIONfjp •LIC. CLASS NO. DWEU.. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS pN NOJff 5f
(commencing with Section 7000)of Division 3 of the BusinessLIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY NaZ QIM 07 CIAss •- BK PG VALIDATION
SQ. FT. NO;OF NO. OF CHECK
License Number6i!�,&C! Lic. Class,(. SIZE STORIES FAMILIES ONE VALUATION
DESCRIPTION OF WORK M(3Ok' NEW ❑
Contractor_; /S/V ega.T'e Date $ O a
F if ADD ❑ Bim' ►
❑I am exempt under Sec. iGGo
ALTER ❑ p.
BAP.C. for this reason REPAIR ❑ $
Date: I USE OF
EXISTING BLDG. DEMO' ❑
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION (PRINT) NO. DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT ByEl
t.
I, as owner of the property, or my employees with BUILDING
RIESSSS 33131? 11,3.Li
wages as their sole compensation,will do the work and �
the structure is not intended or offered for sale(Section 1 LOCALITY , I TIE t S
7044, Business and Professions Code.) MOVING TEL. t!
I,as owner of the property,am exclusively contracting CONTRACTOR NO. TOTAL 1113 -63
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code.). ADDRESS CHECK y j:�.-ti:
w..
CONSTRUCTION LENDING AGENCY PINYARD HWY TOTAPROP. LANE FROM WIDT' CHANGE
I hereby affirm that there is a construction lending agency for I
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name -, ,•�s,� / CDMA Re # 13 4 1 AM 1 l.Permit Fee v
Lender's Address g� ,
I certify that I have read this application and state that the Issuance Fee oc -7—f CDMA P/C#
above information is correct.I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee to ILDMA Perm. #
and hereby authorize representatives of this County to enter
upon a above-mentioned property for inspection purposes.
0 m SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent f irate