HomeMy Public PortalAbout8734 WENDON ST_Building__ WORKERS"COMPENSATION DECLARATION I l L,-` 1! ._
hereby affirm fI have certificate of consent to self P P L �AT I�+ D N F RI'`®I N G P E RM I T
insure, or a certificate of-Workers'Compensation Insurance,
of a certified copy thereof(Sec. 3800•Lab. C.) I
C .�d rM(� COUI�iTY'OF LOS ANGELESBUIL®INI AND SAFETY
Policy No. Company BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ?�J�I��
❑ Certified copy is filed with the county building insp c- BUILDING t
tion department. _ ADDRESS \�tc 6 N LOCALITY C_
C'� l � NEAREST J
Date /" ` - ApplicantCITY ZIP CROSS ST. ff
CERTIFICATE OF EXEMPTION FROM WORKERS' ;t(p •�NO.OF BLDGS. -ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON L07 ....� MAP BOOK I PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP
hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. 0
cc TEL. } SPECIAL y-
I certify that in the performance of the work for which this OWNER J E 6 NO. CONDITIONS tL
permit is issued, I shall not employ any person in any mannerDI TRIC? GROUP I TYPE FIRE PROCESSED BY 0
so as to become subject to the Workers'Compensation Laws. I ADDRESS - O �
CONST. ZONE U
1 -3 09
Date Applicant CITY 4GkL_ Zip `" 77 5� STATISTICAL CLASSIFICATION ICATION A CONDO. 0
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. / U
'Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. CA • DWELL. UNITS LU
Compensation provisions of the Labor Code, you must forth- CA
ADDRESS � SEWER MAP
with comply with such provisions or this permit shall be TEL,,r�1/�j JJ 1 z
deemed revoked. CONTRACTOR '- ' NOd'CJS'O BK. + PG, VALIDATION r
LICENSED CONTRACTORS DECLARATION LIC: ��+t
1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Q NO. Z-t VALUATION
(commencing with Section 7000)of Division 3 of the Business and i LIC
• �J ODO
Professions Code,and my license is in full force and effect. CITY (3 ft CL CLASS $ v(
SQ.FT. NO.OF NO.OF CHE K "
License Number � ��49Lic.Class SIZE STORIES FAMILI ONE
Contractor ? Date �'��� DESCRIPTION OF WORK �7' Q '�"p NEW ❑ $
❑
ADD
I am exempt under Sec. EA O a r'
ALTER ❑ FINAL � rs,•�y ��-
B.BP.C. for this reason I D !� E REPAIR E] DATE I,�
USE OF
Date' EXISTING BLDG. PLACEDEMOL ❑ By r G
Signature � � ' '• APPLICANT TEL. Y
OWNER-BUILDER DECLARATION PRINT NO. 6D
I hereby affirm that I am exempt from the Contractor's License ADDRESS d13 6s— S h 7 A
Law for the following reason (Section 7031.5, Business and
Professions Code): PRESET
❑ DRSS1, as owner of theproperty, or my employees with ADE
i l :.'.63
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITYJ.
7044, Business and Professions Code). MOVING TEL.
❑ 1,as owner of the property,am exclusively contracting CONTRACTOR NO. •C % 1 l
with licerised 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 coristruction lending agency for FRONT D
the performance of the work for which this permit is issued P.L.
tSec. 3097, Civ. C.). SIDE
o P.L.
Lender's Name r
3 'P.C.Fee$ Permit Fee
Lender's Address
i 1 certify that I have read this application and state that the Issuance Fee Sa 0-
above information is correct. I agree to comply with.all County Investigation Fee
aa ordinances and State laws relating to building construction, Total Fees
f, and hereby authorize representatives of this County to enter
::on t entioned proper for inspection purposes. ••
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date 1 es
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