HomeMy Public PortalAbout9854 WENDON ST_Building__ WORKERS'COMPENSATION DECLARATION
•I'hereby affirm that I have certificate of consent self APPLICATION FOR B U I.DI.N G PERMIT
insure, or a certificate of Workers' Compensation Insurance,
dt a�ertifLed copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.9A& ►)2 1MXompany- FrA-1- >- 01r,0 N SQ O" BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS
O—Certified copy is filed with the county building inspec- BUILDING
tion department. ` ADDRESS 5 C- iJ T
Jc+''e 1� 4/q ��5� C L.An o� _ CITY T r� a 'lam ZIP I 7 LOCALITY
Date pplicant�_�,, NO.OF BLDGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT U K ) y NOW ON LOTCROSS ST.
COMPENSATION INSURANCE ASSESSOR
(This
'section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOO sibs AGE 0 z 5 PARCEL D O
hundred dollars ($100)or less.) _t TE¢ S USE ZONE MAP
OWNER ,a 1 r p U&A,g d.��L$G 8s5t NO.
I certify that in the performance of the work for which this
SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS 0(i5 s 'C U-1 P-i/ 0 a w / CONDITIONS a
so as to become subject to the Workers'Compensation Laws. O
CITY ZIP /7 g G V
Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY Ce
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER . NO. JJ 6 9 i J4l eI CONST. ZONE I
Exemption, you should become .subject to the Workers'
Compensation
Compensation provisions of the Labor Code, you must forth- ADDRESS d Z 0 el_ lr t_' i)/v .o� '3 V 3 a-
with comply with such provisions or this permit shall be TELA' S ATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR' �O NO.T 6 e1 S 9.9It _
LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Is a a 114r7LP NO. 2 7 t 9 T5 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC. e
and Professions Code,and my license is in full force and effect. CITY p w r+ C CLASS BK /— PG. VALIDATION
�1 SQ. FT NO.OF NO. OF CHECK
License Number 5Z7 Y 2 56r Lic. Class r, SIZE fi-q I STORIES 1,—e FAMILIES BNP ONE
L 1'( ( DESCRIPTION OF WORK L p/ NEW ❑ VALUATION
Contractor�/1!'O r•�� Date �� ADD ICJ
El ,
I am exempt under Sec. -re kit c.v— C� ,+R✓fi S 7t�''Q
ALTER 1:1
B.BP.C. for this reaso P,:vo p-r e� ��Y o v to', REPAIR ❑ $
Date- USE OF %
EXISTING BLDG. DEMOL ❑
Signature �'�";_r APPLICANT TEL• '� FINAL // ?g
OWNER ILDER Q LARAT16N (PRINT)�� ,� �// sfi� NO. g 6 S `{ DAT /Z fPZ�
I hereby affirm that I am exempt from the Contractor's License ADDRESS $d Z o .-..�(�ty ./�
Law for the following reason (Section 7031.5, Business and FINAL
/�&
Professions Code): PRESENT By 1
ElJBUILDING SG ' O,`, _ �t r•'- t
I, as owner of the property, or my employees with ADDRESS 0..:
wages as their sole compensation,will do the work and _
the structure is not intended or offered for sale(Section LOCALITY -,o fe.> ,,. !.✓<0'—Sa a d-
7044, Business and Professions Code.) MOVING TEL.
El 1,as owner of the property,am exclusively contracting
CONTRACTOR [J 001-� NO.
with licensed contractors to construct theec
j
rot Sec- ;'i t.-, ;-• -.
p ( ADDRESS
tion 7044, Business and Professions Code.)
REQUIRED EXI
YARD HWY TOTAL SETBACK FROM ST. NECK
—r -
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L. °-111'tt7G e•`_i.
(Sec. 3097, Civ. C.). SIDE
(� P.L.
Lender's Name. L IL11 'M
P.C. Fee$ Permit Fee LDMA Ref. #
Lender's Address Pn id �� ► - 744f-
')
I certify that I have read this application and state that the Issuance Fee y LDMA P/C#
above information is correct. I agree to comply with al I County Investigation Fee (70
ordinances and State laws relating to building construction, Total Fee / LDMA Perm. #
and hereby authorize representatives of this County to enter
upon he above-men•tined prop rty for inspection pur ose .
) I SEE REVERSE FOR EXPLANATORY LANGUAGE
ignat Ap cant or Agent Da