HomeMy Public PortalAbout5929 ROWLAND AVE_Building__ WORKERS'COMPENSATION DECLARATION
re a certificate
that I.have certificate of consent to self APPLICATION FOR BUILDING P E RM I T
insure, or a certificate of Workers'Compensation Insurance,
j�.%a certified copy thereof(Sec. 3800, Lab. C.)
r COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
BUILDING
1:1FOR APPLLCANT TO FILL IN ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING ,/ r/�
tion department. ADDRESS l LOCALITY ,7N ,C
NEAREST
Date Applicant CITY ZIP 7 7 CROSS ST. L
CERTIFICATE OF EXEMPTION FROM WORKERS' `' / / NO.OF BLDGS. / ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT (J NOW ON LOT 1 2 MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. 3 USE ZpNE L�!
hundred dollars($100)or less.) TEL. �y 11
I certify that in the performance of the work for which this OWNER 3 NO. "C�W IL
permit is issued,I shall not employ any person in any manner 'r� ! /� DISTRICT G QUP TYPE FIRE PROCf�SED BY O
ADDRESS L/ L Li D CONST ZONE /L
so as�to/�becomesu ject to the Workers'Compens o Laws. //� 1.
Date`' ' Applicant ` CITY ZIP d �2 STATISTICAL CLASSIFICATION APT. IcTP57NOTICE TO APPLICANT: If, after making this a ifica of ARCHITECT OR TEL. 4 1
ENGINEER NO. CLASS NO. DWELL. UNITS 7 �
Exemption, you should become subject to Workers' #A
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be
deemed revoked. TEL'
CONTRACTOR NO. BK. PG, VALIDATION
LICENSED CONTRACTORS DECLARATIONLIC. 2 7 1 5 0 A
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS zd, NO. VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC, # o 0 o o 2 3
Professions Code, and my license is in full force and effect. CITY CLASS $ ,
SQ. FT. NO.OF 9 NO.OF / CHECK I o 3 7 a 0 5
License Number Lic.Class SIZE �Q�� STORIES / / FAMILIES / ONE '
)
Contractor Date DESCRIPTION OF WORK V u & NEW $ �' /� V o o 3 7 a 05 6
❑ I am exempt under Sec. ADD ❑
P ALTER REPAIR E] FINAL 94F0 6o2-87
B.&P,C.'for this reason ❑ DATE
q74 USE OFFIN
Date' EXISTING BLDG. DEM OL El
Signature APPLICANT /� �P TEL. �j By �`'— ;976Z
OWNER-BUILDER DECLARATION PRINT ALS (� JD U Z.I NO. `d / # 0 0 0 0
I hereby affirm that I am exempt from the Contractor's License ( o - 6565
Law for the following reason (Section 7031.5, Business and ADDRESS �f o 0 0 5 5
Professions Code): PRESENT
t� BUILDING ��j�� 0 — 7
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. # 0 a 00 �,
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. 1 - 53250
with licensed contractors to construct the project (Sec- o OHI-99:c`L =
tion 7044, Business and Professions Code). ADDRESS 0 O�y 9 /nyu
REQUIRED TOTAL SETBACK FROM EXIST. �[JL
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 for which this permit is issued P.L.
tSec. 3097, Civ. C.). SIDE
o ,
P.L. t
'r Lender's Name
3 P.C. Fee$ �t Permit Fee t
Lender's Address /c
I certify that I have read this application and state that the Cr(J s Issuance Fee •V�
( above information is correct. I agree to comply with all County Investigation Fee
ordinance and State la relating to building construction, Total Fee I` .56
and her y authorize epre eMotives of this County to enter
upon a tioned roperty for inspection purpa
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signatur of I or Agent Date ®s