HomeMy Public PortalAbout6053 ROWLAND AVE_Building__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to selfi APPLICATION D'
insure, or a certificate of Workers'Compensation Insurance, F �
)U 1 L ' PERMIT
or a certified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES •, BUILDING ALt1® SAFETY lj�/l/Ri( Z.Q D
Policy No. Company
BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
Certified copy is filed with the county building inspec-
tion department. ADDRESS �� LOCALITY
NEAREST
Date Applicant CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT d 90 NOW ON LOT � MAP BOOK PAGE PARCEL
(Th'F4 section need not be completed if the permit is for one s6 USE ZONE MAP
TRACT BLOCK LOT NO. NO.
hundred dollars($100)or less.)
.- TEL. o �j .{ .i t SPECIAL �
I certify that in the performance of the work for which this OWNER .1)t D� NO.�a�! to CONDITIONS CL
permit is issued,I shall not employ an person in an manner DISTRICT GROUP TYPE FIRE PROCESSED BY U
P P Y Y P Y CONST. ZONE V
so as to become subject to the/W�orkere Compensation Laws ADDRESS O5- /�. . Qk • °� r PC
Date ApplicaNY 1, CITY l� ZIP �c+ STATISTICAL CLASSIFICATION ' APT. C
NOTIC TOAPPLICANT: If, after making this Certificate of ARCHITECT OR TEL.
Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS CL
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be r TEL.
d
deemed revoked. CONTRACTOR p - BK. PG,
LICENSED CONTRACTORS DECLARATION r -� IC. VALIDATION
'`
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS/ 0/0/ C->,S 9 ST
• 'c- ALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC. p
Professions Code,and my license is in full force and effect. CITY C CLASS a 6
SQ. FT. NO.OF NO.OF CHECK ."
License Number Lic.Class SIZE STORIES FAMILIES ONE
Contractor Date DESCRIPTION OF WORK NEW ❑
Neu)` Rob ADD ❑
I am exempt under Sec. (i1
ALTER ❑ FINAL �
B.BP.C. for this reason REPAIR
DATE G
USE OF Q FINAL
Date: EXISTING BLDG. Q C DEMOL ❑ By y� �..e«►
Signature APPLICANT TEL.
OWNER-BUILDER DECLARATION PRINT NO.
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section 7031.5, Business and ADDRESS
Professions Code): PRESENT
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.
I,as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SMACK YARD HWY TOTAL SETBACK
LINE WIDTH 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.
`a Lender's Name
� P.C. Fee$ Permit Fee
- Lender's Address
rI certify that I have read this application and state that the Issuance Fee ®•
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee39
and hereby authorize representatives of this County to enter °
upon the above-mentioned property for inspection purposes. ;
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Ant or Agent Date ®s