HomeMy Public PortalAbout6003 RENO AVE_Building__ F7VORKERS' COMPENSATION DECLARATION
reby affirm that I have r certificate of consent to ..If
A P P L I CATION FOR. BUILDING PERMIT
�'t�in�ire, oi''a certificate of Workers' Compensation Insurance, .
or a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
- Policy No. Company ,
El Certified copy is hereby furnished.•. FORAPPLICANT TO FILL IN ADDRIESSS E'.wo
❑ Certified copy is filed with the county building inspec- V BUILDING �S
Tion department. ADDRESS O V(J / ,,�� /��
Date Applicant' CITY l6 C �� ZIP• 7r✓ LOCALITY ALL• `.1
rNO.OF BLDGS. NEAREST'
CERTIFICATE-OF EXEMPTION FROM WORKERS' SIZE OF LOT tj 0%� L +J C/ NOW ON LOT CROSS ST. eu w \,c4oz
'
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) `- Q TEL. G
OWNER t^�e ' 4� _0. — [�� USE ZONE NOP �/1 /_S
I certify that in the performance of the work for which this ,��/t^� p� i SPECIAL "7V tU }
per it is issued, I'shall not employ any person in any manner ADDRESS vC�./ IV @ e—AA d ` O
CONDITIONS
s as to become subject to the Workers'Compensation Laws. CITY e, �� ZIP �g O 0
Date Applicant ARCHITECT OR TEL. r , DISTRICT GROUP TYPE FIRE PRO ES Y O.
NOTICE TO APPLICANT: If, after making this:Certificate of ENGINEER t�I.rJ YIE� NO. CONST. t-
9 CONST. ZONE U
Exemption, you should become subject to the Workers' �j z
Compensation provisions of the Labor Code, you must.forth- ADDRESS ✓ �J 3 N
with comply with such provisions or this permit shall be . TEL. STATISTICAL CLASSIFICATION APT. GOND Z
deemed revoked. CONTRACTOR ��%41 Er` NO. s� [ V —
.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 LIC.
and Professions Code,and my license is in full force and effect. CIN CLASS BK. PG. 7 VALIDATION
SQ. FT. NO OF NO.OF a CHECK
License Number Lic. Class SIZE •ia STORIES FAMILIES / ONE
VALUATION
DESCRIPTION OF WORK [R * NEW �0 V'
Contractor Date ;4 + ADD $
- ❑I am exempt under Sec. (�' �`�h
VvL j t ll. VK polo
_I ALTER ❑
BAP.C. for this reason W + 1��/1 AVL C Y- �. ��Z �� REPAIR ❑ $
lJ1 USE OF
Date: EXISTING BLDG.' Qr<�j&eAII .e; DEICANTpMO' ❑
Signature APP(PRItJT) q\j L3� �. y r` TEL 3 `�Of FINAL _ _ -
OWNER-BUILDER DECLARATION. �— DATE �26� -
I hereby affirm that I am exempt from the Contractor's License ADDRESS rj�J Iv• t`C-vl�i 1 Eve- L c l'�
Law for the following reason (Section 7031.5, Business'and FINAL
Professions Code)•: PRESENT By --—_ -�--�
BUILDING �k i 3 _.= t
❑ I, as owner of the property, or my employees 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. ► s';.:; ;,1L "
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed•contractors to construct the project (Sec- ADDRESS ` N
tion 7044, Business and Professions-Code.)
REQUIRED TOTAL SETBACK FROM EXIST. r % --••• -
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 fot which this permit is issued ' P.L. 4 L/
(Sec. 3097, Civ. C.). SIDE - 'tP
P.L. r tl i.�u :rT;
1+•
Lender's Namei'-
LDMA Ref. #
P.C. Fee$ �3 Permit FeeiY" , Ott,
Lender's Address a °ti
G
a I certify that I have read this application and state that the Issuance Fee LDMA P/C
B above information is correct. I agree to comply with all County. Investigation Fee
ordinances and State laws relating to building construction, Total Fee ev LDMA Perm-# -
and ereb atharize�epr fives of this County to enter
upg a e-menti d proper for inspection purposes. + -s* y
SEE REVERSE FOR EXPLANATORY LANGUAGE
y .
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Si nat re of App ant or Agent Date r-•� "0 r=+ C3 mgr