HomeMy Public PortalAbout6445 TRELAWNEY AVE_Building__ e WORKERS COMPENSATION DECLARATION
',Pkffoirm that I have a certificate of consent to selfAPPLICATION - FOR BUILDING PERMITsure a}%cendicotgtof Workers Compensation Insurance
or a certified copy thereof jSec 38DO Lob C•) -
d COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company - BUILDING
El Certified copy is hereby furnished FOR APPLICANT TO FILL IN AUILUII
El Certified copy is filed with the county building inspec- BUILDING
DDRESS
tion deportment i ADORES$ /
Date Appbcont , _ CITY - - -ZIP / - -- LOCALITY =z Ixt
CERTIFICATE OF EXEMPTION FROM WORKERS - - - NO OF BLDGS - NEAREST
COMPENSATION INSURANCE SIZE OF LOT O/G$ NOW ON LOT Z GLOSS Si
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO ASSESSOR
hundred dollars($100)or leu) MAP BOOK PAGE PARCEL
TEL 77$pppNNN -
I certify that in the performance of the work for which this OWNER / '��"�"d NO ,/ / NO >
IL
permit a issued I shall not employ any person m any manner _ _ _ 'K`r SPECIAL IL
b as to become subject to the Workers mpensation L s 's'DORE55 - CONDITIONS
Date !17'67 Apphc Cm 6L ZIP / 7 O - m
NOTICE TO APPLICANT If making this C, i scare of '�'rEER� TEL
DISTRICT GROUP TYPE FIRE BV
Exemption you should ome subject to the Workers - CONST, / Z tJ
Compensation provisions of the Labor Code, you must forth ADDRESS S �/ _ _ d
with comply with such provisions or this permit shall be - - TEL STATISTICAL CLAS$LFICATION APT ONDO
deemed revoked CONTRACTOR L[.iNC2 NO 76 O/C/
LICENSED CONTRACTORS DECLARATION - - - -- LIC CLASS.- DWELL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEAR MAP
(commencingry
with Section 7OD0)of Dewn 3 of the Business and _ _ _ _ __ LIC
Professions Code and my license is in full force and effect CITY CLASS 1 PG VALIDATION
SO FTS /JYs NO OF _ NO OF _ CHECK
License Number L¢ Cloys SIZE / 7 �- STORIES FAMILIES ONE
NEW
VALUATION
Contractor Date DESCRIPTION OF WORK - --- - : -
�s
L am exempt under Sec
ALTER
B 8P C for this reason REPAIR 6 i
Duro USE OF
EXISTING BLDG DEMOL -f 61 4,5 A
Signature APPLICANTTEL RNAL nn n e . . e
OWNER-BUILDER DECLARATION (PRINT)
PRINT O U I 'elft_A No DAh W ,/ #_ * 23
I hereby off irm that I am exempt from the Contractors license
Low for the following reason Section 7031 5 Business and ADDRESS FINAL
to—ions Code) BUILD! BY 12- 19-86
I, as owner of the property, or my employees with ADDRESS
wages m their sole compensation,will do the work and LOCALITY ;
the structure is not intended or offered for sale(Section '
7041 Business and Professions Code) - - MOVING - _- TEL -
I as owner of the property am exclusively contracting CONTRACTOR NO
with licensed contncrors to construct the project (Sec-
non 7044 Buane ,and Professions Code) AD ,N \•`' ' i
CONSTRUCTION LENDING AGENCYIX I D YARD ,y _TOT t
SETB •_ ` : __ _ _
APROP LINE WIDTH i
I hereby affirm that there is o construction lending agency for FRONT 2 6 7 9 A
the performance of the work for which this permit is issued PL - - - — - --
(Sec 3097, C,v C ) SIDE # • • • e 1
7
Lender's Nome P L I - 27375
$ /] LDMA Ref Y
lender s Address C Fee i Permit Fee / 3. ' • • 2 7 3 7 5 FL
I certify that I have rend this application and state that the _ - Ivuonce Fee / N V LDMA P/C Y # 3 8'�
above information is correct 1 agree to comply with all County Investigation Fee -
ordinances and State jaws reloting to building construction Tour Fee- LDMA Perm E
d and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE '
Sigigture of Applies or Agent - Date-