HomeMy Public PortalAbout6202 SULTANA AVE_Building__ WORKERS':.OMPENSATION DECLARATION j
r ' .L,Hrrekiy cffj�m that'I Rave a cef tificate of consent to�self A P P L LCAT I O.I F.O R B U I L D.I IV.G P E RM.I:T
f:� ;Asure, ora certify�^ppte of V11orkers'Compensation Insurance,
br a certified copy'fi+ereof.(Sec:,3800,.Lab..C,) COUNTY OF-LOS ANGELES "BUILDING AND SAFETY
Policy No. - Company
ElBUILDING
`'Certified"copy.,is Hereby furnished. ,' FOR APPLICANT TO FILL IN ADDRESS �0�-001- Sum- o+A
❑ Certified copy is filed with the'county building inspec- BUILDING e�� �v�-- .� A
tion department. ADDRESS t/L p[_E 7
Date APFlieant CITY' I�Jo/7.7�E t37° TIP
LOCALITY
_ IVO.OF BLDGS. NEAREST.
CERTIFICATE OF;EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON.LOT CROSS ST. Z /
COMPENSATION INSURANCEAMAP BOOK PAGESSESSOR
-(This section need not'be completed if the permit-.Is for one TRACT�0 C BLO
- CK LOT NO. .196 4-8 OO'� PARCELP6
'
-hundred dollars ($100)or less.). ': ' ' .- -,• � TEL, ,
OWNER V-A?Alue- aFyNO.rLB`/•' SS79 USE ZONE MAP
,I.certify.that in the.performance of the work for which'this
permit is issued, I shall not employ any person in any manner ADDRESS ��� �ur—�� - --� SPECIAL "' CL
CONDITIONS
so as,to.beco a subject to the Wor rs•Compensation Laws.. O
8CRY 7-Y ZIP CJ .
Date 9'z .Applicant,' u �`Y ARCHITECT TEL.
• NOTICE TO APPLICANT: If, after, making this .Certificate of •
ENGINEER. /+?.• f/C�7�/15 N0,33 �ScIIS� DISTRICT GROUP TYPE FIRE PROCESSED. O
Exemption, you should become •subject'.4a the Workers' U -•W �c CONST.'/ ONE V
Compensation,provisions of'the Labor Code,.you;must fo�th- ADDRESS: :/,qs: �• /� tr Zc�S/d ��"� `✓ Y - a
with comply,with,such provisions or thispermit shall be TEL• STATISTICAL CLASSIFICATION .. APT.'. CONDO. N
deemed revoked.:'- CONTRACTOR A'r' /-�v NO.���157� Z
LICENSED CONTRACTORS DkL`ARATION '.... " /�� ..LIC: CLASS NO. �1 DWELU''UNITS
ADDRESS 3&0 BSE t O "A ;D13 NO. �� —
I hereby affirm that I am licensed under provisions of Chaptei-9'.• SEWER MAP
(commencing'with Section 7000.)of Division 3 of the Business gG� LIC.
and Professions Code;and m license is in full,force and effect. CITY' . /}tI>F' CLASS , �—y VALIDATION
y BK: PG ��to,
�y SQ. FT NO.•OF NO OF CHECK
Liceiise'IVu osfv.0� `Lic:Class'•N 'SIZE STORIES jr FAMILIES ONE
VALUATION
Contractor �C �` � �' :'q�' DESCRIPTION OF RK �/ � NEW
rid ADD ❑ $ �O�CrC> `
❑I am exempt under Sec.—'
ALTER .❑
B.BP.C. for this reason ^02 �4�a�+dll11 — �/9'7�F ;
REPAIR ❑ �"•
�� l)eite, USE OF A
EXISTING BLDG DEMLOL ❑ %�.: r
Signature - APPLICANT e A i'.TEL:, FINAL'` L ?, ��'.:,';? =.
OWNER-BUILDER,DECLARATION (PRINT) /�/i1RI-y NO,iI�SL%3t57�J'
DATE if—:342-
I hereby affirm that I am exempt from the Contractor's License 3�� •
ADDRESS' e /ODNit70uS�d4�Afl
Law for the followirig reason (Section 7091.5, Business and FINAL" i
Professions Code.): PRESENT B i=it•S. ,-
BUILDING y
❑ I, as'owner of"the property,•or.'my employees with ADDRESS I �_:i 3:'
wages as their sole compensation,will do the work arid =
'._the structure is not intended or offered for.'sale(Section LOCALITY
7044, Business and Professions Code.) MOVING TEL. ' , r , - y �; y^ r '
1 ❑ 'I,as owner of the property,am exclusively cbntracting CONTRACTOR NO. �''� 1 I_i li.! °�_' — =• -1=
with•licensed'contractors to construct the project.(Sec- �� 'r
ADDRESS ,
.tion 7044, Business and•Professions Code.). A.II^i• a i'
-REQUIRED YARD FIWY TOTAL SETBACK FROM', 'EXIST.: A,fAj�./-I" �
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is.a.construction lending agency for FRONT
.the performance of the,work for which this:permit Wi'ssued PA.
'^L? i3 r.r•
(Sec. 3097; Civ. C.). SIDE }`l.` (,—' , _:. .• .
L'ender's Name r ,(r
_ 11 -7 � 22'
� CDMA°Ref. #
P.C..'Fee$ �J`O /� Permit FeetO
Lender's Address r ,
I certify that I have read this application and state that.the � '• . Issuance Fee
3 ove information is correct. I agree to,�mpl with all Count Investigation Fee y/
ori rices and State laws relating to building co6struction, Total Fee / / CDMA Perm. #
(: an��—e by autho`ize representatives of"this�aunt.to enter
abo(�1gt` 'ohed,property for inspepur gses. _
o ioL S_E_E_REVE_RSE FOR EXPLANATORY LANGUAGE ,
Signature,of Applicant or Agent D to �;