HomeMy Public PortalAbout6011 SULTANA AVE_Building__ WORKERS'COMPENSATION DECLARATION rte,
I hereby affirm that I have a certificate of consent to self �I ��TION O m 'U I`®I P E ISM I T
insure, or a certificate of Workers'Compensation Insurance, u ®®
or a certified copy thereof(Sec. 3800, Lab. C.)
PaNo.W0005279 P y Beaver Ins. Co. BUILDING
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy
Com an 1'=•�'-'•
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS O a
13Certified copy is filed with the county uildin ,'nspec- BUILDING
tiondepartment. ADDRESS 6011 Sultana LOCALITY
NEAREST
Date 7/7.6/84 Applicant CITY Temple City zip 91780 CROSS ST.
CERTIFICATE OF EXEMPTION F M RKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION IN RAN E 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 oZ V 8 7
hundred dollars ($100)or less.) TRACT BLOCK LOT NO.
TEL. SPE��� SPECIAL >
I certify that in the performance of the work for which this OWNER Mr. L. M. Fielding No. 87-4140 CONDITIONS ®.
permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY Q
so as to become subject to the Workers'Compensation Laws. ADDRESS 6015 Sultana //'� 3 CONST. -ZZONE rd
09
CITY Tem le Citv ZIP 91780 O
Date Applicant STATISTICAL CLASSIFICATION APT. CONDO. 1—
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL.
Exemption, you should become subject to the Workers' ENGINEER None NO. CLASS NO. 11 1 . UNITS 0.
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be TEL.
deemed revoked. CONTRACTOR United Roofing CO.NO.223-4081 BK. r,PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC. ; 11 a' '
I hereby affirm that l am licensed under provisions of Chapter 9 ADDRESS 1821 Daly St. NO: 137650 VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC. 1107.00
Professions Code, and my license is in full force and effect. CITY Los An eleS 90031 CLASS C-39 * $
13 50 C-39 SQ.FT S ORIOF FAMIOLIES Coil
ONE
License Numb e '� Lic.Class ;
Contracto o
7/16/84 DESCRIPTION OFWORKreroofin with NEW E] $
tI
ADD ❑ ,. ...�.-.;:.�..,n• ;;.....r. .a. .
❑I am a mpry der Sec. 3—tab fiberglass shingles over
/ ALTER ❑ FINAL
B.BP.C. for this reason asphalt shingles. REPAIR ❑ DATE i_? �,' t% F
Date: USE OF
DEMOL C] FINAL ,
EXISTING BLDG. R2S1deriCe B
Signature APPLICANT TEL. Y t,' �Q t
OWNER-BUILDER DECLARATION PRINT United Roofln CO. NO.223-4081 (�j(,�
I hereby affirm that I am exempt from the Contractor's License / l r V., r
Law for the following reason (Section 7031.5, Business and ADDRESS1821 Daly St. Los Angeles, 90031
Professions Code): PRESET
❑ BUILDING
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 o o •-�E,75
7044, Business and Professions Code). f MOVING TEL. o 7 17_
27
1,as owner of the property,am exclusive) contractingCONTRACTOR None NO. ` c
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
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.
tSec. 3097,Civ. C.). I SIDE
i
P.L.
'r Lender's Name
Lender's Address P.C.Fee$ None Permit Fee 26.25
• ,
I certify that I have read this application and state that the Issuance Fee10.50
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee 36.75
and hereby authorize re resentat'ves of this County to enter ,..
upon the abov •ment' ed pr rfy for inspection purposes.
7/16/84 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu of A
,p016nt or Agent Date ®s