HomeMy Public PortalAbout6008 ROWLAND AVE_Building__ •WORKERS' COMPENSATION DECLARATION I'
. y 'y.,
(sdre o, rm that I have r certificate of consent to self r-APPLICATION FOR BUILDING PERMIT
. :
'insOre, or atcertificate of Workers'Compensation Insurance,
••,or a certified copy thereof (Sec.'3800,Lab. C.) "'
tO&TY OF LOS ANGELES BUILDING AND SAFETY
Policy No.=" Company
` Certified copy is hereby furnished.• FOR APPLICANT TO BUILDING''FILL IN gppREss O - B-Lts' L.0
❑ Certified copy is filed with the county building inspec- BUILDING' s& . .
tion department. ADDRESS O
iC,CAUTi
•Date ; Applicant clrr .T C i ZIP p� •.r
NO.•OF BLDGS. NEAREST,
CERTIFICATE-OP EXEMPTION FROM-WORKERS' ' ' SIZE OF LOT D' NOW;ON LOT ' CROSS ST.
''COMPENSATION'INSURANCE, ASSESSOR ((��
This section need not be completed if the,permit is for one TRAGI BLOCK. LOT'NO. '27� MAP BOOK PAD PARCEL
hundred dollars ($100)or less.)'
OWNER' NO. USE ZONE MAP G
NO.
• I certify that in the perforrrtance-of the work for which this.. `� �- ,(//� SPECIAL
permit is Issued, I shall not employ'any person in•any manner Vi ADDRESS e/%i �/ ,CONDITIONS a
SQ as to become subject to.the Workers'Compensation Laws. �j O
CITY zip
Date Applicant `IL ARCHITECT OR
TEL
DISTRICT GROUP TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this.Certificate of ,v ENGINEER NO.2 !.IPL't O '
Exemption, you.,-should become subject. to, the Workers' CONST. ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS ��d j ✓ Q a
with 'coinply with such provisions or this permit shall be l TEL. STATISTICAL CLASSIFICATION APT. CONDO. N
• deemed revoked. - � '�'- :. -' _ CONTRACTOR l A(a NO. .-
Z '.
LICENSED CONTRACTORS DECLARATION
LIC. CLASS No. _DWELL. UNITS_
Thereby affirm that I am, under provisions of Chapter 9 ADDRESS NO.
LIC. SEWER MAP
(.commencing with Section 7000)of Division 3 of the Business Y � •. CLASS '� / • • '
and Professions,Code,,and my license,is in full force and effect. CITsrPG 1,'4 •• '•VALIDATION
SQ. FT. ' NO. OF NO.OF r CHECK -
License Number Lic. Class SIZE ?'). 1 STORIES FAMILIES, ONE
:. 1 VALUATION
Contractor' Date 11 "� DESCRIPTION OF WORK' NEW .❑ t ,`t
❑I am exempt urider, Sec.-, ! G 1 Q ADD-- ❑ $ ' . _ �•�._,.. -
rte! ALTER ❑ A ► ;fes.:.-•r .a■ .�'.
B.&P.C. for this reason t�
:(ti�:
Date: USE OF REPAIR:❑ -r
APPLICANT-
EXISTING BLDG. A W MOL I)E ❑ 1t"tir q ry_
APPLICANT- �L, -7 138' 9
Signature FINAL + j�r. • ery■
OWNER-BUILDER•DECLARATION
(PRI "NO: • _
`'.• s..;ti DATE " S • '• ,..t i ; j,,•;.
I hereby affirm that I am exempt from the Contractor's License �::i s._:, - i ,!,�,�a:s'.:_ i 4,r� `IJ`_-`. r_.. . _
Law for the following reason (Section 7031.5, Business and ADDRESS FINALM1 8 -••
Professions Code): PRESENT By -
❑ ' I, as owner;of the property, or m)i employees with ADDRESS 7
7.
wages as their sole compensation,will do-the work and LOCALITY :, !TE11S
the structure is not intended or offered for sale(Section
7044, Busiriess and Professions Code.) MOVING TEL ,' J, •ti -
I;as owher'of the-'property,am exclusively contracting CONTRACTOR NO. /,.n, TOTAL ���f■+-'T
with licensed contractors to construct the project (Sec- DRESS v (V' i•1 IE �'' L�.41.2z,
tion 7044,�Business and Professions Code.)'- �:• P _r
REQUIRED ' YARD HWY TOTAL SETBACK FROM- EXIST. V = 1° ';',�`�fAOE ■�Itl
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is,a construction lending agency for FRONT "
the perfiirmance of the work for which this permit is issued P:L. '
(Sec. 3097, Civ. C.),. SIDE• l;OUi�—�l'!C 1 113/?#1
\► 1\��� P:L. I
Lender's Name o� pG�Fee �. 62154 1 PM 12'-24
�0 ; LDMA.Ref. #
$ O1 a /•
Per Fee
Lender's Address i La Caw seA nul 21 1' P:C: p
I certify that I,have read this application and state that the issuance Fee ' LDMA P%C#
above•information•is correct.I agree to comply with all County Investigation Fee' /, /� ✓�
I ordinances and State'laws relating.'to building construction, Total Fee c%, oc r Oi -LDMA Perm. # r
( and here6y'authorize representatives of this.County to enter
9 upon the.above- a tinned property for inspection purposes.
9J_ SEE REVERSE FOR EXPLANATORY LANGUAGE _
Signature ofApplicant or Agent Date Vie''