HomeMy Public PortalAbout9415 WOODRUFF AVE_Building__ WORKERS'COMPENSATION DECLARATION
870135 LA �
hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑olicyN0007146 CompanyBeaver Ins. BUILDING
Certified copy is hereby furnished. i FOR APPLICANT TO FILL IN ADDRESS &bOMEE
r 17 Certified copy is filed with the county building inspec- BUILDING ! ,/Ja (2)
tion department. ADDRESS 9415 Woodruff LOCALITY l'
NEAREST
Date 4/22/87 Applicant VirginRoof Co CITY Temple Cit ZIP CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' No.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE I SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USErE MAP
hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO.
TEL. SPECIAL
I certify that in the performance of the work for which this OWNER Morris Turner NO. CONDITIONS 0.
permit is issued, I shall not employ any person in any manner as above DISTRICT YPE FIRE PR ESSED BY O
CONST. ZONE U
so as to become subject to the Workers'Compensation Laws. i ADDRESS y 5 PONT
C9
J J
Date Applicant I CITY ZIP STATISTICAL CLASSIFICATION APT. C O. U
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. 71Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. 71 UNITS
Compensation provisions of the Labor Code, you must forth- I ADDRESS SEWER MAP
with comply with such provisions or this permit shall beT ° 0__111EL
deemed revoked. CONTRACTOR Virgin Roof Co N0287-0507 r BK. /—PG, VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS P.O. BOX j NO 160650 VALUATION
(commencing with Section 7000)of Division 3 of the Business and San Gab r ie 1 LIC. C 39 1000.00
Professions Code,and my license is in full force and effect. CITY CLASS $ Poo.
C39 SIZS .E 1600 NO.OF ISTORIES 1 FAMILIES CHECK ONE
License Number Lic.Class
S
Contractor Virgin Roof Co Date 4/22/B7 DESCRIPTION OF WORK Over existing NEW ❑
❑I am exempt under Sec. roof apply Class A fiberglass ADD ❑`
ALTER ❑ FINAL .i /v
B.&P.C. for this reason shin lew. 16 s s. DATE —
REPAIR ❑
Date: USE OF dwelling DEMOL ❑ F
EXISTING BLDG.
Signature
APPLICANT
IR NTT Virgin Roof Co TEL 287-0507 ;" ;26924A
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License 'ADDRESS PO BOX J, San Gabriel, CA 9 1778 ® # o a o 0 0 1
Law for the following reason (Section 7031.5, Business and I +
Professions Code): I PRESENT 0 0 B
❑ BUILDING J
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). I MOVING TEL.
I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- I ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY I SET BACK YARD HWY 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.
tSec. 3097, Civ. C.). SIDE
m i P.L.
Q Lender's Name
P.C. Fee$ Permit Fee 30.00
Lender's Address
I certify that I have read this application and state that the I Issuance Fee 10.50
a above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, 40.50
and reby authorize representatives of this County to enter I Total FeeEMU
upon he above-mentioned pr erty action p rposes.
o SEE REVERSE FOR EXPLANATORY LANGUAGE
SI ure of Applicant or Agent Date I ®6