HomeMy Public PortalAbout5955 SULTANA AVE_Building__ WORKERS'COMPENSATION DECLy!NRATION
I hereby affirm that I have a certif1cg1e'•of consent to self P
insure, or a certificate of Workers'Compensation Insurance, A P D L I CAT I O N FOR U I L D I N G P E RM I T
,.or a certified copy thereof(Sec. 3800, Lab. C.)
_ �. COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
Policy No. 33 Companyk4 "
❑ Certified copy is hereby furnished.• FOR APPLICANT TO'FILL IN BUILDING f
f ADDRESS - ' oa
Certified copy is filed wA the county building inspec- BUILDING
y•' tion department. ADDRESS iV• • LOCALITY I
NEAREST
Date l .Applicant — CITY (o , ZIP - O CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLD ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON.LOT MAP BOOK PAGE' PARCEL
•(This section need not be completed if the permit is for one USE ZONE MAP 7
hundred dollars($100)or less.) a. TRACT BLOCK LOT'NO. ' _ () NO.
TEL iW'�� SPECIAL �
I certifythat in the .w
'e erformance of the ork for which this OWNE TEL CONDITIONS >
permit is issued,I shall not employ any person in.-any manner '•' L DIS ICT .GROUP TYPE FIRE PROCESSED BY 0
so as to become subject to the Workers'Compensation Laws. ADDRESS r Q .CONST ZONE
CITY• e ZIP C O
Date Applicant ' STATISTICAL CLASSIFICATION APT. CONQO. V
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR , T /
'Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. DWELL. UNITS
'Compensation provisions of the Labor Code, you must forth- ADDRESS t �' ` SEWER MAP
-with comply with such provisions or this permit shall be TEL. Z
�+
deemed.revoked. CONTRACTOR NO. BK. PG,% / VALIDATION
LICENSED CONTRACTORS DECLARATION LIC: .
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION cs�r�QB
(commencing with Section 7000)of.Division-3 of the Business and LIC.
-Professions Code,and my license is in full force and effect. CITY o CLASS
SQ NO.OF NO.OF" CHECK
lucense Number Lic.Class-- S109 LASTORIES F LIES ONE
PTION OF W $ = 1 9a3'P
'• DESCRIORK NEW '' !
Contractor Date
❑I am exempt under Sec. ALT ER FINAL --- oLo 2 3,
❑ S (kf'��C/-_/�""
B.&P.C.for this reason REPAIR ❑ DATE 12 -.342b8
Date: E STING BL G. DEMOL ❑ FI AL /c_t Gt�- o 4 29 A L I
Signature APPLPRINT a NO. (j 5 1 3_8 3
OWNER-BUILDER DECLARATION ,�--•��
I hereby affirm that I am exempt from the Contractor's License ADDRESS CJ�L G 14-,0fX04 1
Law for the following reason (Section 7031.5, Business and
Professions Code):
PRESENT", 43 7 a 2 A
I, as owner of the property, or my employees with ADDRESS
wages as their.sole compensation,will do the work and4 o o a
the..structure is not intended or offered for sale(Section LOCALITY
7044, Business•and Professions Code). MOVING TEL. 2 0 o 6630
I❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
' with licensed contractors to construct the project (Sec- ADDRESS o 0 o c5 6 3 0
'tion-7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST. Q 7, 1 5-83
CONSTRUCTION LENDING AGENCY. SET BACK YARD HWY PROP. LINE WIDTH �r . . ` /
I hereby affirm that there Is a construction lending'agency for FRONT G z f/
jthe performance of the work for which this permit is issued P.L. -3 7 0,3 A
Sec: 3097, Civ. C.). SIPE
yf o 0 0 0 0 1
a Lender's Name
2 - 4.9200
P.C.Fee$ Permit Fee
Lender's Address 'a a'L; , 2-006.
sI certify that I have read this application and state that the b Issuance Fee d S
above Information.is correct. I agree to comply with.all County Investigation Fee + 0 7 1 5-8 3 I'
ordinances and State laws relating to building construction, Total Fee ..� t Q d ''
land hereby authorize representatives of this County to enter
;upon the above-mentioned property for inspection purposes. r
kklC SEE REVERSE FOR EXPLANATORY LANGUAGE
o Signature bf Applicant or erit a ®s ;