HomeMy Public PortalAbout6040 ROWLAND AVE_Building__ .WORKE&S'COMPENSATION,DECLARATION lei
ereby affirm fiat I haver cern om a of consent to self A P P V�CATION FOR BUILDING PERMIT
ure, or a certificate of Workers'Compensation Insurance,
a certified co y thereof(Sec. 3800, Lab. C. !COUNTY OF LOS ANGELES BUILDING AND SAFETY
Company i
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec- BUILDINGlee
r
tion department. ADDRESS Q LV I/k LOCALITY
f NEAREST
to Applicant CITY '7 0jT ZIP /29d CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
is section need not be completed if the permit is for one USE ZONE MAP
ndred dollars($100)or less.) TRACT BLOCK LOT NO. NO. �a
TEL SPECIAL >
ertify that in the performance of the work for which this OWNER r g NO. " — ) CONDITIONS
IL
rmit is issued,I shall not employ any person in any manner DISTRICT .GROUP TYPE FIRE PRO ESSED BY_ O
as to become subject to the Workers' om enation Laws. ADDRESS da O Lt+ CONST.. ZONE
I P � r"', 3 0 r9
to ?2—�3 Applicant r CITY �G ZIP STATISTICAL CLASSIFICATION CONDO. I-
OTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. gg ,,
ENGINEER NO. CLASS NO. DWELL.UNITS
emption, you should become subject to the Workers' a
MMMMIiiiiI
ompensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP to
ith comply with such provisions or this permit shall be ^� i
semed revoked. CONTRACTOR lt. NO. �R, �J BK. LPG,/-3 VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS / / NO. VALUATION
commencing with Section 7000)of Division 3 of the Business and LIC. Y $ 'f
'rofessions Code, and my license
is in full force and effect. CITY t-G CLASS fU poll 32, �p &ZEA STORIOES FAMIOLIES CONE
icense Number- �_�Lic.Class
NEW ❑ $ o �
:ontractorCFiu �;� Date �r2 z 3 DESCRIPTION OF WORK w o 1 1
I am exempt under Sec. ' ADD "r
y— ❑ ` � r L C.
ALTER DA FINAEL
B.$P.C. for this reason REPAIR ❑
USE OF FINAL By
Date: EXISTING BLDG. DEMOL ❑ ray— `rt"a,
Signature APPLICANT TEL. V G
OWNER-BUILDER DECLARATION PRINT NO.
hereby affirm that I am exempt from the Contractor's License ® c�,
aw for the following reason (Section 7031.5, Business and ADDRESS
'rofessions Code): PRE ENT
BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and 7�,Z s�3
the structure is not intended or offered for sale(Section LOCALITY
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- rADDRE
tion 7044, Business and Professions Code).
TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SETBACK_ YARD HWY PROP. LINE WIDTH
hereby affirm that there is a construction lending agency for
he performance of the work for which this permit is issued eSec. 3097, Civ. C.).,ender's Name
PermitFee J
.ender's Addresscertify that I have read this application•and state that the Issuance Feeibove information is correct. I agree to comply with all County n Fee
irdinances and State laws relating to building construction,
ind hereby a rize representatives of this County to enter Total Fee
ipon th -mentioned pro nspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE ®s
Signature of Applicant or Ajent Date