HomeMy Public PortalAbout5543 1/2 SANTA ANITA AVE_Building__ .'NORKERS'COMPENSATIOV DECLARATION
"1 hereby affirm that I have a certificate of consent to self
inpure, or c�.c;rtificate of Workers'Compensation Insurance, APPLICATION F OR BUILDING PERMIT
or a certifigd copy thereof(-Sec:3800, Lab. C.)
3 g0 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No tW D ompany 6#& 6 _
1:1 . Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING S /
ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS 5543 1/2 Santa Anita Ave.
'—
Date 19410Applicant CITY Temp-l—e City Temp-l- ZIP 917 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORK RS' NO.OF BLDGS. NEAREST
•COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST.
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT 44319 BLOCK LOT NO. MAP BOOK" PAGE PARCEL
TEL. USE ZONE MAP J�i1 a }
I certify that in the performance of the work for which this OWNER NO. _ NO. ICO "7�J
permit is issued, I shall not employ any person in any manner 217 W. Las Tunas Dr.. SPECIAL L
so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS Ou
CITY San Gabriel ZIP 1776
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT G OUP TYPE - FIRE PROCESSED BY I..
ENGINEER NO. — CONST. ZONE L7
Exemption, you should become subject to the Workers' W
Compensation provisions of the Labor Code, you must forth- ADDRESS 6.6, v 5 y
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CO DO. U)
deemed revoked. CONTRACTOR Same as. owner NO. ,/�0 'I'''
LICENSED CONTRACTORS DECLARATION• LIC, CLASS NO.�DWELL.UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK PG 0-0 V VALIDATION
r / �( SQ' FT' 1735 NO OF FA OF CHECK
License Numberss��� Z�i✓ Lic.Class �✓� SIZE STORIES FAMILIES ONE VAL TION
NEW
Contractor �cG�1 COU, . ��' Date DESCRIPTION OF WORK ADD 11 0 0
❑ I am exempt under Sec. Slncle family detached E] (J lJ , 4 3 2
ALTER
B.BP.C. for this reason condominims -f-jlddsf, 2r12 REPAIR ❑ $ 0 0 0 0
USE OF 0
� 4
Date: EXISTING BLDG. DEMOL E] I 0 O 0 c=i
APPLICANT TEL. �f
Signature PRINT) John Plount NO. 576-8737 FINAL G 0 3 3 1 -86
OWNER-BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License ADDRESS FI
Law for the following reason (Section 7031.5, Business and
'Professions Code): PRESENT B
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as theif 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. V
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). REQUIRED YARD HWY TOTAL SETBACK FRO A 5 0 2 8 A
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT # 0 0 o 0 0 1
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDEr1 - 75525
P.L.
Lender's Name ��jj,{ LDMA Ref.# " \_ '' �' -.c, 7552535
01 P.C. Fee$ t J�/L O 6 Permit Fee
- Lender's Address ,,ll 0 7, 1 5 86
p I certify that I have read this application and state that the Issuance Fee 1s LDMA P%C#
above information is correct. I agree to comply with all County Investigation Fee
d ordinances and State laws relating to building construction, Total Fee �O� LDMA Perm.#
J and hereby authorize representatives of this County to enter
S upon the above-menti ed property for inspection purposes.
�f. SEE REVERSE FOR EXPLANATORY LANGUAGE
�. Signaturf Applicant or ggent Date
O�