HomeMy Public PortalAbout6265 RENO AVE_Building__ s+.••- WORKERS'COMPENSATION DECLARATION
APPLICATION "WILDING PERMIT
� FC_I hereby affirm that I have a certificate of consent to self O
insure, or a certificate of Workers'Compensation Insurance, I
or a certified copy the (Sec. 3800, Lab. C.) COUNTY-01`10S ANGELES I BUILDING AND SAFETY
Policy No. Company
E] Certified copy is hereby furnished. ` FOR APPLICANT TO FILL.IN ' BUILDING r 3
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING r.D '
tion department. ADDRESS
Date Applicant I CIT r ZIP- LOCAILITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDG9. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one I ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP,BOOK PAGE PARCEL
I r TEL' USE ZONE MAP
I certify that in the performance of the work for"which this OWNER NO '� 0. NO.
permit is issued, I shall not employ any person in any manner SPECIAL
so as to become subject to the Workers'Compensati n Law . I ADDRESS
��F`O CONDITIONS Q.
ZIP
Date Applicana
ARCHITECT OR TEC.
NOTICE TO APPLICANT: If, after making'this Cer icate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PR SED BY O
Exemption, you should become subject to the orkers' s CONST. ZO V
Compensation provisions of the Labor Code, you must forth- ADDRESSv
with comply with such provisions or this permit shall be
TEL STATISTICAL CLASSIFICATION APT. NDO. N
deemed revoked. CONTRACTOR P N z
LICENSED CONTRACTORS DECLARATION r LIC, CLASS NO. y� DWELL.'UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 j ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business andLIC i SEWER MAP
Professions Code, and my license is in full force avid effect. CITY CLASS BK VALIDATION
SQ. FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor pate DESCRIPTION OF WORK NEW $
j r ADD ❑,
❑1 am exempt under Sec. II • ' ALTER
B.$P.C. for this reason USE OF �REPAIR ❑'• '$ ;29 0 3.6 A
❑
Date: EXISTING BLDG. DEMOL
o 0,0 0,0s1
Signature APPLICANT TEL. ' FINAL
OWNER-BUILDER DECLARATION PRINT NO. DATEO,
1 o o 4 Q 5 0
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
Professions Code): PR E T g o 0 0 4 Q 5 0:9
�-� BUILDING
jJ I, as owner of the property, or my employees with ADDRESS 0'2 2 4-
wages as their sole compensation,will do the work and LOCALITY
the structure Is not intended or offered for sale(Section
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 SETT BACK YARD HWY TOTAL SETBACK
LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L. .
Lender's Name -yt
G�(f LDMA Ref. p
o i P.C.Fee$ Permit Fee Ot
Lender's Address ((((
I certify that I have read this application and state that the Issuance Fee v LDMA P/C#
2 above information is correct. I agree to comply with all County i Investigation Fee
ordinances and State laws relating to building construction, Total PeeZIAJ CDMA perm.11
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
0 4X o � �r. __-1 -gV SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicay or Agent Dote