HomeMy Public PortalAbout5953 SULTANA AVE_Building__ WORKERS'COMPENSATION DECLARATION ®
insureboraafirm certif certificate of Worke s'that I have atificate Compensat on Insurancef P® CT Iof coent to ILI� G' PERMIT
hereor a certified copy thereof(Sec. 3800, Lab. C.)
❑ y p r.5���' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic No�Com an a /vu A � (,
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ,Bo�DR SSv2-
n Certified copy is filed with the county building inspec- BUILDING
J� tion department. ADDRESS 5 LOCALITY
e t r NEAREST J
Date �TApplic6n CITY ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORE r NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT , . NOW ON LOT MAP BOOK PAGE PARCEL
IF
(This section need not be completed if the permit is for one USE ZONE MAP �1
hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. G�
+ G TEL. SPECIAL }
I certify that in the performance of the work for which this OWNER NO. CONDITIONS
permit is issued, I shall not employ any person in any manner DIST ICT GROUP TYPE FIRE PROCESSED BY
so as to become subject to the Workers'Compensation Laws. ADDRESS r i� CONST^ ZONE u
Date Applicant CITY ZIP STATISTICAL CLASSIFI TION APT. CONDO.
NOTICE TO APPLICANT: If, after making this Certificate of qENGI TER OR N .
III
Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. - DWELL. UNITS W
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP 1, RA
with comply with such provisions or this permit shall be ,e
TEL. VALIDATION',
deemed revoked. CONTRACTOR NO. BK. PG,
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION J�oZ �'db
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code,and my license is in full force and effect. CITY CLASS $
SQ. O.OF NO.OF CHECK ®+
License Number Lc.Class SIZ TORIES FAMILIES ONE
NEW $
Contractor Date DESCRIPTION OF WORK o ADD I Ti �' L
❑I am exempt under Sec. ❑
ALTER ❑ FINAL
B.BP.C. for this reason Q REPAIR ❑: DATE �-� " h
Date: F FINAL /I 2 n
fEIST(ING BLDG. DEMOL ❑ ��
Signature APPLICANT _ TEL. By C ;u �+ r
OWNER-BUILDER DECLARATION PRINT) NO. •-
I hereby affirm that I am exempt from the Contractor's License ADDRESS jdd& eL � Ii L 1 ? _
Law for the following reason (Section 7031.5, Business and _
Professions Code): 'PRESENT r3.7 10 4
BUILDING
I, as owner of the property, or my employees with ADDRESS 12
0 0 a o 2
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. 2 0 0 6 6 "3 0
❑ CONTRACTOR NO.
I,as owner of the property,am exclusively contracting a ^ a is (• `
with licensed contractors to construct the project (Sec- ADDRESS Q 7 1 -8 3
tion 7044, Business and Professions Code). " /
REQUIRED TOTAL SETBACK FROM EXIST. ;_ -4 7 O. 1 II V
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. i' 0 a 0 o a 1
tSec. 3097, Civ. C..). SIPE
Lender's Name
P.L.
+'• 2 - 4 920 0
P.C.Fee$ Permit Fee �Q i
�d
Lender's Address
x I certify that I have read this application and state that the ��� .3 Issuance Fee .- �vi S� 1
above information is correct. I agree to comply with all County Investigation Fee L�pp ��jj
ordinances and State laws relating to building construction, Total Fee / 7 iii O a
and hereby authorize representatives of this County to enter
upon the above-mentioned prop for inspection purposes. -
G I SEE REVERSE FOR EXPLANATORY LANGUAGE
o ®S
Signature of Appli ant ant Date