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HomeMy Public PortalAbout6227 SULTANA AVE_Building__ W©RKEW COMPENSATION DECLARATION `insureor a�certif certificate ofoWo ke s'tCompensation Insurance, APPLICATION FOR BUILDING P E RM I T or a certified copy thereof (SSeec. 3800, Lab. .) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoJ7�/b�` rripany BUILDING . Certified copy'is hereby furnished. FOR APPLICANT TO FILL IN AMR ❑ Certified copy is filed with'the c ty buildi nspec- BUILDING tion department.' ADDRESS Date -L �� Applicdnt CITY ZIP s LOCALITY CERTIFICATE OF EXEMPTION FRO W ERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section'need not"be completed if.the permit is for one ASSESSOR hundred dollars'($,1.00)or less.) TRACT LOT NO. MAP PAGE PARCEL OWNER NO.81b �7 USE ZONE MAP I certify that in the performance of the work for which this NO. >. permit is issued,I shall not employ any person in any manner nn Z SPECIAL d so as to becomd subject to the Workers'Compensation Laws. ADDRESS�•yyrr, CONDITIONS Ou CITY ZIP Date' ' Applicant ARCHITECT O TEL. V 140T.ICE TO APPLICANT:' If, after making this Certificate of 3WJ7 Q DISTRICT', GROUP TYPE FIRE PRO SED BY Exemption, you'-sh'ould become subject to the Workers' ENGINEER d�✓ NO. ����jj �) CONST]/ ZONA b Compensation provisions.of the Labor Code, you must forth- ADDRESS IV `�r[/� l v vl, y with -comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFIC TION APT. C DO. deemed revoked. CONTRACTOA/ /9Yrr NO. �� LICENSED CONTRACTORS DECLARATION. LIC, CLASS NO. Z DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Q, .f NO. SEWER MAP ( mmencing with Section 7000)of Division 3 of the Business and LIC. Procofessions Code, and my license is in full force and effect. CITY C BK VALIDATION FT. NO.OF NO.OF CHECK License Number Lic.Class V STORIES FAMILIES ONE DESCRIPTION OF WORK/713 - NEW E] VALUATION ;12 2 Q 6 A Contractor Date xz` /� ADD ❑ ; Ill Ov pill. # 0000273 ❑I am exempt under Sec. ALTER ❑ I - 53550 B.&P.C,for this reason A_ REPAIR ❑ $ USE OFDate-' EXISTING BLDG. A&$ rrf OTISIf DEMOL ❑ o a 5 3 5 5 0 APPLICANT TEL. 0 Signature FINAL Q b 6—85 OWNER-BUILDER DECLARATION PRINT NO. DATE I hereby affirm that I am exempt from the Contractor's License "02- Low for the following reason (Section 7031.5, Business and ADDRESS V06 F L Professions Code): ' P E ENT Y ❑ 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 -2 3 3 $,7 A 7044, Business and Professions Code). MOVING TEL. R , I,as owner of the property,am exclusively contracting CONTRACTONO. 0.0 0 0 0 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY REQUIRED BACK YARD HWY TOTAL SETBACK EFRO WIDT' I 6 4 Q 5 0 1 hereby affirm that there is a construction lending agency for FRONT 6 4 Q 5 0 the performance of the work for which this permit is issued P.L. c o 05= (Sec. 3097, Civ. C.). SIDE 3 P.L. Lender's Name 11, 04 —85 /r :{ LDMA Ref. W� ' 3 P.C.Fee$ tJ` 6 Permit Fee ✓ V = Lender's Address ` e I certify that I have read this application and state that the Issuance Fee /6,.S0 LDMA P/C# i� �!•,�'� +i �.: ( above information is correct. I agree to comply with all County Investigation Fee /� ordinances and tate laws relating to building construction, Total Fee v r�V TDMA Perm.# and hereby a rize re res I tives of this County to enter upon the -men roperty f nspection SEE REVERSE FOR EXPLANATORY LANGUAGE SigOWN,of Applicant or Agent e " O� �4 tel:;ri, A1ORKtRS;.COMPENSATION DECLARATION insure,oc aff artificate of Workers'Compen at on Insurance, APPLICATION FOR BUILDING P E RM I T or a ce ti 'e y r 7f/!(S/�e 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Police •QrtZ ny rPW — BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS S n Ccs' •(� Certified copy is filed with th�bbulldl c- BUILDING n �ntitiion department. ADDRESS w t CLLOCALITYNEAREST Date l Appli ntCITY ( �l ZIP L !2 CROSS ST. �1/ CERTIFICATE OF EXEM RO ERS' NO.OF BLDGS. ASSESSOR COMPENSATIONINSUR E SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ONE MAP hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. 11 �JTEL. SPECIAL I certify that in the performance of the work for which this OWNER C NO CONDITIONS ItL. DISTRICT GROUP ITYPE FIRE PR ED BY O permit is issued,I shall not employ any person in any manner ADDRESS �{ /�f( CONST. / ZONE V so as to become subject to the Workers'Compensation Laws. ✓` PEST/ ¢.' L) Date Applicant CIN ZIP 70 STATISTICAL C "FICA ION ✓ APT. 100tDO. NOTICE TO APPLICANT: If, after makingthis Certificate of ARCHITECT OR TEL. ENGINEER NO. CLASS NO. UNITS eL . Exemption, you should become subject to the Workers' . Q. Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N with comply with such provisions or this permit shall be TEL. deemed revoked. CONTRACTOR 0 O i BK. PG, ♦, VALIDATION LICENSED CONTRACTORS DECLARATION h j LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS yV NO. VALUATION (commencing with Section 7000)of Division 3 of the Business andLIC. Professions Code, and my license is in full force and effect. CITY Mrvj CLASS $ , �J 3 ^ SQ. FT. NO.OF NO.OF CHECK License Number / ,2 2-9 Lic.Clas SIZE STORIES FAMILIES ONE $ Contractor- C11 �_Date DESCRIPTION OF WORK NEW ❑ -2 2 9 7.9 A ADD ❑ I am exempt under Sec. ALTER ❑ FINAL �- � # 0 0 0 0 0 B.BP.C. for this reason REPAIR DATE USE OF e' EXISTING BL DEMOL By V o - 60,50 Signal APPLICANT TEL. ER-B TION PRINT NO. �1" o a o 6 p 5 0 5- I hereby affirm that I a empt tom the Cont tot's License a Law for the following eason (Section 7031.5, Business and ADDRESS Sd , f9�s 9.2 3-8 5 Professions Code): PRESENT A,7 S. _a I, as owner of the property, or my employees with ADDRESS / , 06/ wages as their sole compensation,will do the work and LOCALITY rn/� the structure is not intended or offered for sale(Section I 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). 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. (Sec. 3097, Civ. C.). SIDE b P.L. `o Lender's Name � P.C.Fee$ Permit Fee / ^O� !! - Lender's Address �) n r I certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Investigation Fee ordinanc and State laws relating to building construction, Total Fee and her y authorize representatives of this County to enter g� upo a ve-mentio d roper for inspection purposes. - t D SEE REVERSE FOR EXPLANATORY LANGUAGE Signet of an or Agent D e ®s r