HomeMy Public PortalAbout5715 ROWLAND AVE_Building__ WORT PS'17nMPENSATION DECLARATION .77 f 7
hereby a ea.e ln certificate of consent to self
,insure, or a certificate of Workers'Compenstion Insurance,or APPLICATION FOR BUILDING- PERMIT
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a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified co is hereby furnished. BUILDING
f
• - ❑ copy y FOR APPLICANT TO FILL IN ADDRESS �7
El
Certified copy is filed with the county building inspec- BUILDING n
Tion department. ADDRESS OWLAA /4(r . LOCALITY _
NEAREST
Date Applicant CITY &AMM ZIP 6717296 CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' N0.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT OQ I9O NOW ON LOT �. MAP BOOK ��;PAGE PARCEL
(This section need not be completed if the permit is for one I USE ZONE ffiP nhundreddollars($100)or less:) TRACT BLOCK LOT NO. C� c �✓TEL. p . IAL OWNER J. NO. j I p DITIONS ' O
I certify that in the performance of the work for which this DISTRICT GROUP TYPE FIRE PR ESSE BY t.l
permit is issued, I shall not employ any person in manner C � '� COST. / ZONE O
ADDRESS,57/,15--ti7 fi(� N/� I 'sV
so as to become subject to the Worke omp s ion L s. r w /1� y19
Date Applicant � CITY ae 6 ZIP 7 STATISTICAL CLASSIFICATION APT. CONDO. v
NOTICE TO APPLICANT: If, after makin this Certificate of ARCHITECT OR T ^ ' w
ENGINEER , zvzz" O. CLASS NO. c�DWELL.UNITS—
Exemption, IL
you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be r— J
deemed revoked. CONTRACTOR NO. BK. 46PG,/ e 1C VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VAL TI N
(commencing with Section 7000)of Division 3.of the Business and LIC
Professions Code, and my license is in full force and effect. CITY CLASS $- 00 ,
SQ. FT. s`,� NO.OF NO.OF CHECK
License Number Lic.Class SIZE u� STORIES FAMILIEst ONE
Contr6cfor Date DESCRIPTION OF WORK
NEW ❑ $
❑ I am exempt from the licensing requirements as I am a ��Q ADD
In
licensed architect or a registered professional engineer ALTER ❑ FINAL
acting in my professional capacity (Section 7051, REPAIR ❑ DATE � `;'moi •(}7
Business and Professions Code). USE OF FINAL
EXISTING BLDG. DEMOL ❑ By �� i+
Lic.or Reg.NO. — Date APPLICANT TEL.
PRINT) NO.
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law.for the fcil(owing'reason (Section 7031.5, Business and ADDRESS
,Pessioris Code): PRESENT �f—
BUILDING
I, as owner of the property, or my employees with ADDRESS y �/ r`
wages as their sole compensation,will do the work and '`� ! �7 O
the structure is not intended or offered for sale(Section IF
OCALITY U 7 2
7044, Business and Professions Code). MOVING TEL.
❑ CONTRACTOR NO. #� 0 0 0 0 0
I, as owner of the property, am exclusively-contracting
with licensed contractors to construct the project (Sec- ADDRESS 2 - 521,50
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST. - 5: 21,506
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
1 hereby affirm that there Is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L. 0 7,0'6—8 2
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name e�
'o .C. Fee$ �C� [7 Permit Fee V /
Lender's Address
W I certify that I have read this application and state that the Issuance Fee { S O
°C above information is correct. I agree to comply with all County nvesti anon Fee
ordinances and Stat aws relating to building construction, 9 ��lilt .�j Q
21 and here utho z representatives of this County to enter Total Fee
up o a above ntionedraper ty for inspection purposes.
) SEE REVERSE FOR EXPLANATORY LANGUAGE
� Signa o Applicant or Agent, Dote '
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