HomeMy Public PortalAbout6167 SULTANA AVE_Building__ WQRellKERV WMPENSATION DECLARATION
' 11—s f.ki uq irm that I have a certificate of consent to self
`S insure,br a certificate of Workers'Compensation Insurance, A P PU CAT I O N FOR BUILDING PERMIT
• or a rtified copy thereof
(Sec. 3800, Lab. C.) COUNTY OF.LOS ANGELES BUILDING-AND SAFETY
Policy No. 's arrtan�l Fd'A+� ��� l BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE� 66 6 � �> -
Certified copy is filed with the county building inspec- BUILDING 1��
tion department. ADDRESS �9.1,
Date '9*, Applicant CITY /" %//r�G. Li// ZIP LOCALITY
CERTIFICATE OF EXEMPTION F M WORKERS' S. NEAREST
SIZE OF LOT '7O /�� NOW ON LOT CROSS ST. r
NI
COMPENSATION I RANCE
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO., l J �, MAP BOOK PAGE PARCEL
` TEL. USE ONE MAP
I certify that in the performance of the work for which this OWNERTJII-�er��i' NO. -f NO.
permit is issued, I shall not employ any person in any manner c,� �` kms, SPECIAL.
so as to become subject to the WorkersCompensation Laws. ADDRESS/ / �/�� �►t- CONDITIONS U
Date Applicant CITY Wei/ l/� ZIP 14/ 0 ;
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PRO SSED BY �,
ENGINEER NO. /11\� CONST. ZE MM
Exemption, you should become subject to the Workers' v`�_ Y01' /
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION AP' NDO.
deemed revoked. CONTRACTOR G r{/ ✓ NO. hhlo
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. tJ r DWELL. UNITS fi
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP
(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 BK PG� VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number37 3 4 77 Lic.Class SIZE STORIES FAMILIES f ONE a ,,•+
�-' VALUATION
Contractor.��6%r:-��TLIi"pia e 97~S6 DESCRIPTION OF WORK' "� %�"
NEW O ; Q'/� 3T �L0U
❑I am exempt under Sec. / r�i'�� f ,ALTER ❑ D V u V ,
B.&P.C. for this reason ' SQL• �Cf�7z- �-JX/S/� r' G A4'-If� REPAIR $ • -
Date: USE OF DEMOL ❑
EXISTING BLDG. t l
j v PLICANT TEL• r� FINAL #;24820A
Signature OVA ER-B ILDER DECLA 'PION APPRINT 0.0 0 0
I hereby affirm that I am exempt from the Contractor's License ADDRESS �/ G> Yf�3 IL7"�./�N GG/F%��LG��r;�= FINA :. _ - 56993
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESENT BY I 0 a 5 6 9.9 3 25,
❑ BUILDING Q 6 1 3=5 6
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 ® L
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- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SET BACK YARD' HWY TOTAPSETBACK FROM
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.
(Sec. 3097, Civ. C.). SIDE
P.L.
v Lender's Name rA LDMA Ref. #
P.C.Fee$ R Permit Fee AJ
hl 9 2 A
Lender's Address
I certify that I have read this application and state that the Issuance Fee LDMA P/C# # o o b o 0 1
above information is correct. I agree to comply with all County Investigation Fee /� /,rl�
ordinances and State laws relating to building construction, Total Fee 1/ " LDMA Perm. # ( 0 6 8'4.1,0 0
u and hereby authorize representatives of this County to enter
upon bove-m ned operty for inspection rp�urrpoosses. i 0 0 6 81.0 Q�
G"f-' F6
r^ SEE REVERSE FOR EXPLANATORY LANGUAGE W16/Y6 ®'
ig ueof & Date