HomeMy Public PortalAbout5703 RIO HONDO AVE_Building__ WORKERS'COMPENSATION DECLARATION r
hereby affirm that I have certificate of consent to self APPLICATION
P P L I T I ) �1 �I L®I PERMIT 7L
insure, or a certificate of Workers'Compensation Insurance, @1`1 L�9ls�
or a certified copy thereof(Sec. 3800, Lab. C.) 1
� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS @
❑ Certified copy is filed with the county building inspec- BUILDING 2 Q/1 r
tion department: i ADDRESS V � I
/�!'� qf7fV
Date Applicant CITYVW 6.1� L/I! ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' + .t-NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT 1 O ZB0NOW ON LOT— CROSSI ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
J!t a Q�L ) J TEL. USE ZONE MAP
I certify that in the performance of he o for ich this , OWNER ((�n���T (� 9V NO. NO.
permit is issued, I shall not emplo y r n in y' man r ADDRESS - 0 O 1 CONDITIONS O
SPEC AL
so as to become sub' t to the r rs i n L s.
N0a _v Applicant" CITY ZIP f/NO. p;
NOTICE TO APPLICANT: If, after making this a ifica a of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
Exemption, you should become subje to the Workers' ; ENGINEER CONST. ZONE f�
Compensation provisions of the Labor Co e, ou must forth- ADDRESS 3
with comply with .such provisions or th ermit shall be TEL. STATISTICAL CLASSIFICATION
APT. CONDO. 4n
deemed revoked. CONTRACTOR NO. I' e
LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business andLIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS ,BK PG VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class I SIZE STORIES FAMILIES ONE
+ ! 3TIO
EZ ®
Contractor Date DESCRIPTION OF WORK NEW ❑;
r-1I am exempt under Sec. ffill 0 40912010 ADD
ALTER ❑:' I
B.BP.C. for this reason REPAIR. ❑ $ '
' USE OF
Date: EXISTING BLDG. DEMOL ❑
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
Pr fessions Code): PRE ENT BY '
BUILDING
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 r' 1 Jr 1.7A
7044, Business and Professions Code). MOVING TEL.
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. " 0 a o 0 0 1
with licensed contractors to construct the project (Sec- I ADDRESS
tion 7044, Business and Professions Code). •2 0 - 68.63
REQUIRED TOTAL SETBACK FRO EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH « S
I hereby affirm that there is a construction lending agency for FRONT a 0 0 6 �� L 3"
the performance of the work for which this permit is issued P.L. O F 2 v_8 4
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name LDMAIRef. #
P.C.Fee$ Permit Fee r
Lender's Address
I certify th I ho a rea this application and state that the Issuance Fee 'P/C#
ab o fo ati is car ct. I agree to comply with all County Investigation Fee A
or ce nd ate I ws relat' g to building construction, Total Fee f LDMA perm. #
J a re au r' esent Lives of this County to enter
( u v - erty inspection purpo es.
0
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sli natur"ifint or ent Date 0