HomeMy Public PortalAbout6228 RENO AVE_Building__ WORKERS',COMPENSATION DECLARATION
'
I hereby affirm that I have a certificate of consent to self !
insure,or a certificate of Workers'Compenstion Insurance,or APPLICATION FOR BUILDING PERMIT
a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES I BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS C_
❑ Certified copy is filed with the county building inspec- BUILDING //�
tion department. ADDRESS LOCALITY e<z 01///1
p NEAREST
Date Applicant CITY ZIP p CROSS S .
CERTIFICATE OF EXEMPTION FROM WORKERS' O.OF BLDGS.. ASSESSO401,
COMPENSATION INSURANCE SIZE OF LOT d y NOW ON LOT . MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one n ------ 71 USE ZONE MAP Z Q
hundred dollars ($100)or less.) TRACT �/ BLOCK LOT NO. i NO. C�-
TEL. y�� SPECIAL
I .certify that in the performance of the work for which this OWNE a 0. 85-35 CONDITIONS
permit is issued, I shall not employ any person in any manner [[__ D STRICT GROUP TYPE FIRE PROCESSED BY U -
(f! a /C 9
so as to become ADDRESS CON ZONE subject to the Workers'Compensation Laws.
� D % O
CITY ZIP 79U
Dat Applicanr� T STATISTICAL CLASSIFICATION AFT., CONDO. 1-�
NOTICE TO AENGI
PPLICANT: If, after making this Certificate of ARCHIECT.OR TEL. 71
Exemption, you should become subject to the Workers' ENGINEEER NO. CLASS NO. 1 DWELL. UNITS
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this-permit shall be -
deemed revoked. CONTRALTO � NO S ,p 03S BK•ilM PG• VALIDATION
LICENSED CONTRACTORS DECLARATION
LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS L.Rh6c�i NO '.,L VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC. id Oa
Professions Code, and my license is in full force and effect. CITY CLASS $
SQ. ` ' 1`10.OF NO.OF CHECK
License Number `{ ��� Lic.Class -1L! SIZ STORIES FAMILIES ONE
�j� DESCRIPTION OF WORK NEW $� 7y,�� L'J cam ' _r7 (I,8 A
Contract . Jar GL/s�7 &a1ABote ADD
I am exempt from the licensing requirements as I am a
icensed cfrchitect or a registered professional engineer ALTER ..FINAL
9 y 'P P y ( REPAIR DATE 1
actin in m rofessional 'capacity Section 7051, I
Business and Professions Code). USE OFP DEMOL Y FINAL / 2 a 237,38
EXISTING BLDG. - C d Ti By r�'-L-✓. f�
Lic.or Reg.No. Date APPLICANT TEO.�L. t c' C 3 7,O m
OWNER-BUILDER DECLARATION
(PRINT) N �163 i
I hereby affirm that I am exempt from the Contractor's LicenseADDRESS 7 Al RSt' f4RTL ���� 1 0,03-83
Law for the following reason (Section 7031.5, Business and
,Professions Code): PRESENT
[:JIBUILDING
, as owner of the property, or my employees with ADDRESS
wages ds their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL.
1, as owner of the property,am exclusively contracting CONTRACTOR NO. ;
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
SET BACK
CONSTRUCTION LENDING AGENCY YARD HWY
PROP. LINE WIDTH
I Hereby affirm that there is a construction lending agency for' I FRONT
the performance of the work for which this permit is-issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name /�fl
Lender's Address
P.C. Fee$ Permit Fee ,� P
I certify that I have read this application and state that the Issuance Fee
above information is correct. I agree to comply with all County Investigation Fee ^�=
4 ordinances and State laws relating to building construction, Total Fee � �
and hereby authorize representatives of this County to enter 3' .
f
upon the above-mentioned roperty for inspection purposes.
3a a / /b� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa a of Applicant or Agent Date es