HomeMy Public PortalAbout6155 1/2 SULTANA AVE_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that f have certificate of consent to Self APPLICATION - FOR BUIL®I N G PERMIT
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES BUILDIG AND SAFETY
❑ , Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING t^�l
❑ Certified copy is filed with the county building inspec- BUILDING �
ADDRESS
tion department. ADDRESS
Date Applicant CITY �1 C.t ZIP L '90 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' d b NOW O
l l7 N OT 'L CROSSSST. ,
NO.OF BLDGS.
COMPENSATION INSURANCE SIZE OF LOT f t:
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR
hundred dollars($100)or less.) MAP BOOK PAGE PARCEL
OWNER e�y� NO. �d�r USE ZONE MAP
I certify that in the performance of the work for which this NO. IVE
permit is issued, I shall not employ any person in any manner SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS OPnav
JJAI IT O
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Date Applicant"'! f t•c (CITY ZIP r '
ARCHITECT OR TEL.
NOTICE A PLICANT: If, after m tng'this Certificate o DISTRICT GROUP TYPE FIRE PROCESSED.BY O
Exemption, you should become subject to the Workers' ENGINEER NO. y
_ ? CONST._ ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS � W
with comply with such provisions or this permit shall be
deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. JDO. U)CONTRACTOR _ NO.
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 VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
NEW ❑ VALUATION
Contractor Date DESCRIPTION OF WORK $
Q
I am exempt under See. akc Do L a kAtA i f w
ADD
s ALT R
B.BP,C. for this reason - of , AIR ❑
Date: USE OF LW G—*"/1j (3�'YJf6lf}+j I,& DEMOL ❑
EXISTING BLD
Signature APPLICANT �� • TEL. FINAL z 9 8 319 A
OWNER-BUILDER DECLARATION PRINT IVB w NO. DATE ,
I hereby affirm that I am exempt from the Contractor's License I # 0 0 0.0 o
Law for the following reason (Section 7031,5, Business and ADDRESS FIN o - 7(150
Professions Code): By
BUILDING
I, as owner of the property, or my employees with ADDRESS /P- 0'0 0 7(a 5 0 um
wages as their sole compensation,will do the work and LOCALITY
the structure Is not Intended or offered for sale(Section o609-88
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- i
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SET
SET BACK PROP.LINE WIDTH
I hereby affirm that there is a construction lending agency for tln4estiglatlon
the performance of the work for which this permit is Issued
(Sec. 3097, Civ. C.). SIDE
Lender's NameLDMA Ref. R
Lender's Address Permit Fee /'1 certify that I have read this application and state that the Issuance Fee 0, LDMA P/Cabove information is correct. I agree to comply with all County ee
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter Total Fee LDMA Perm. N
upon the above-mentioned property for inspection purposes.
g — w I SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date