HomeMy Public PortalAbout9236 WEDGEWOOD ST_Building__ WORKERS'COMPENSATION DECLARATION 1
i
hereby affirm that I have certificate of consent to self i APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers'
p
kers'Com ensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.) j COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Pv v FOR APPLICANT TO FILL IN BUILDING -�
Certified co is hereby
ed. ADDRESS G' Q
Certified copy ' d with the
ca
building inspec- BUILDING 3 fjF
tion de ent. ADDRESS I !/+��/`
Applicant i CITY ZIP Mo LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' i 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 1 ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP,BOOK PAGE PARCEL
�J TEL.. . USE ZONE MAP
I certify that in the performance of the work for which this OWNER �L( S NO. NO.
permit is issued, I shall not employ a per n in an anner ��y�� ✓ SPECIAL
so as to become subject to the Ware pens n a ADDRESS K�°V!/ CONDITIONS
CITY ZIP f� j
Date A Applicant � ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after maki is rt icate of I ENGINEER NO. DISTRICT GROUP TYPE FIRE SSED BY
Exemption, you should become subject to th Workers' CON ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be TEL. Add. STATISTICAL CLASSIFICATIO CONDO.
deemed revoked. CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION ��•,,/� LIC, CLASS NO. DWELL. UNITS
-
A hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS a2f //�J . 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 �• r Z' CLASS F/ BK PGVALIDATION
ov 1,0SQ. FT. NO.OF NO.OF / HECK
License Num r / Lic.Class SIZE STORIES ' FAMILIES ONE o 0
X%"
' NEW VALUATION �o a
Contractor D D460Fate / D RIPTI� F WO K 1 `J ADD 0 $ 1011�
o o a 5 9.2 5 0
I am exempt under Sec. ,tryALTER p 1 2 3 0-4 8 8 w
B.BP.C. for this reason G REPAIR $ N
USE OF �r }�
Date' EXISTING BLDG. S. �. DEMOL
Signature APPLICANT &W 44 / NO. �TEL. // Z�✓ FINAL
OWNER-BUILDER DECLARATION PRINT /sf /�� r,� DATE
I hereby affirm that I am exempt from the Contractor's Licen ADDRESS ���� /�/. Z FIN
Law for the following reason (Section 7031.5, Bus* and
Professions Code): PRE N B
BUILDING
1, as owner of the properf my employees with I ADDRESS
wages as their sole co sation,will do the work and '
the structure is n ended or offered for sale(Section i LOCALITY
7044, Busi and Professions Code). MOVING TEL.
5I, a ner of the property,am exclusively contracting CONTRACTOR NO.
-- it licensed contractors to construct the pr (Sec- ADDRESS
tion 7044, Business and Professions Co
REQUIRED TOTAL SETBACK FROM
CONSTRUCTION LENDING NCY I SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a constr ton lending agency for I FRONT
the performance of the work fo hich this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name I&A/I LDAIA
a j P.C.Fee$ Permit Fee Ref.M
Lender's Addre
S I certify th have read this application and state that the Issuance Fee LDMA P/C M
g above i rmation is correct. I agree to comply with all County Investigation Fee
ao, ordi ces and State laws relating to building construction, Total Fee 1 LDMA Perm.N
N a here auth ' rep motives of this County to enter
C
n th ov ntione or inspection purposes.
m '�,• SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of plicant or Agent Date