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HomeMy Public PortalAbout9246 WEDGEWOOD ST_Building__ WORKERS'COMPENSATION DECLARATION hereby affirm that I have certificate of consent self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers'Compensation Insurance, t or a certified'copy thereof(Sec. 3800, Lab. C.) ' COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No f� Company=� 7 ��, r�U�P/ BUILDING ,-0'—Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS W4 46G(761az)0049� ❑ Certified copy is filed with the county buildi spec- BUILDING ! _ tion department. 42��-GQ w!�� ADDRESS ,(v r+ CITY ILZIP LOCALITY DateplicanT �(�" NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROO WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL. OWNER _ZTa VO• �� USE ZONE MAP I certify that in the performance of the work for which this NO. q SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS / 1 CONDITIONS o_ so as to become subject to the Workers'Compensation Laws. q O CITY C r ZIP / Cf Date Applicant ARCHITECT OR Tn. W NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP ONST. FIRE PROCESSED BY l0 Exemption, you should become subject to the Workers' ..�•D r/ `� / V� NE Compensation provisions of the Labor Code, you must forth- ADDRESS U �/ "•t with comply with such provisions or this permit shall be i TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO,�DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC. cc�� SEWER MAP and Professions Code,and my license is in full force and effect. CITY 8✓`' CLASS (i J BK VALIDATION !�^ �• SQ. FT. NO. OF NO.OF CHECK License Number_ �+� 7 7 Lic. Class ` SIZE STORIES FAMILIES ONE /•� ��JJ NEW ❑ VALUATION Contractoiw���zy��r��Date �� DESCRIPTION OF WORK � h DO /j 9 L Q6r4 ADD ❑ ; / ► ❑I am exempt under Sec. �/•+� r ALTER ❑ B.&P.C. for this reason /�' REPAIR Mille- USE OF EXISTING BLDG. DEMOL ❑ Signature 'v APPLICANT FINAL T NO. R OWNER-B ER DECLARATION DATE ? f la-I& I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT B _ ❑ I, as owner of the property, or my employees with ADDR SS =s wages as their sole compensation,will do the work andLL�{ LOCALITY �. ' the structure is not intended or offered for sale(Section =�:_,:?_' 7044, Business and Professions Code.) MOVING TEL. ❑ CONTRACTOR NO.1, as owner of the property,am exclusively contracting •�+�•-t: ■r-ti with licensed contractors to construct the project (Sec- ADDRESS )tt� a■� ,y tion 7044, Business and Professions Code.) r•t�rt.v; REQUIRED TOTAL SETBACK FROM EXIST. =r.L:•,; rt;? { CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ;• -°1=�°L` 1 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. Lender's Name 8 ? G LDMA Ref. # 3' 7, P.C. Fee$ Permit Fee tt t;�_ ., Lender's Address 1•$rl.t,i■ 61. I certify that I have read this application and state that the Issuance Fee C;? • LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee // ordinances and State laws relating to building construction, Total Fee J- .(6 9 LDMA Perm. # and hereby authorize rep sentatives of this County to enter upon t=bove-mentic, property inspection purposes. 0 41 df©'�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur Applicant or Agent Date