HomeMy Public PortalAbout9421 WOODRUFF AVE_Building__ w ;. 4�5%'A RKF1911 COMPENSATION DECLARATION
I)Keret r c it certif carte of Workers's'tCompensat on ificate of ensurancelf APPLICATION "FORBUILDING PERMIT
InSUr 1,
or y'V b l lh ec. 3000. Lab. C.)
J t •��� ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑a PBUILDING
iicy No. mpany O
Certified copy is hereby furnished. ' I FOR APPLICANT TO FILL IN ADDRESS
(r"]�ertified copy is filed with the county building inspec- BUILDING u�DIL a •
IIW3 tion department. /� ADDRESS /J h r r" ,
Dote' -91'-e? Applicont4D04Wd At1 al- �lf��A CITY '9W 1 YGl9 6/ ` ZIP fro LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOV / �p NOW ON LNO.OF OT• CROSS ST. J
EST
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one {f`� �ff/ ASSESSOR
hundred dollars($100)or less.) TRACT BLOCK LOT NO. L� MAP BOOK PAGE PARCEL
�J�q TEL. USE NE MAP
I certify that in the performance of the work for which this OWNER ,ClOrkU d NO.WS NO,
permit is issued, I shall not employ any person in any manner SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS 11 �q r CONDITIONS U
Date Applicant CITY - Par A ZIP inn W
ARCHITECT �p�A'TEL•qq p DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of � �jj 36 Ce•(r/rrl+�"�NO,J �3 V ® CONST. ZONE F-
Exemption, you should become subject to the Workers' ENGINEER j 1 , / 2 V
Compensation provisions of the Labor Code, you must forth- ADDRESS 13-33 6/ /l- a 7'1 DV V .-J w
with comply with such provisions or this permit shall be
deemed revoked. �,� TEL. STATISTICAL CLASSIFICATION APT. ONDO.
CONTRACTOR�D Il` z NO. N
LICENSED CONTRACTORS DECLARATION /1LIC, pp� /' CLASS NO. 11 DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS//--"3 �v v/ NO.7 6 y�y ft-k
(commencing with Section 700D)of Division 3 of the Business and �,�11 LIC. SEWER MAP
Professions Code and my license is if full force and effect. CITY J`� / CLASS 'f: BK PG VALIDATION
J SQ. Fi.. (�>� NO.OF f NO.OF / CHECK
License Nuumbber�U O Lic.Class es SIZE v STORIES
FAMILIES ONE
Contra�r'"d a'd�� LAD., 7'� � 7 DES//CRIPTIION OF WORK l/T� �� NEW ❑ VALUATION
❑ l� t1" !{ /a 1.�� OpM1^ ADD ; Pool
I am exempt under Sec. ALTER ❑
B.BP.C. for this reason REPAIR ❑ $
Date: USE OFC' DEMOL ❑
EXISTING BLDG. 1 f� /�'
Signature APPLICANT TEL. rr��rr FINAL / �7 5 3.7 A
g OWNER-BUILDER DECLARATION PRINT o /A�f Cjl Q.Lt` NO. FINAL f/'� DAT;41—(,v11 # 0 0 0 0,0 1
1 hereby affirm that I am exempt from the Contractor's License //`3 3 �� V/�.�,�. /�-,a�C �d}
Law for the following reason (Section 7031.5, Business and ADDRESS FINA -:1 o'1 4 3.6 3
Professions Code): PREbENT BY
❑ I, as owner of the property, or my employees with ADDRESS 0 0 143,635
wages as their sole compensation,will do the work and
the structure is not Intended or offered for sale(Section LOCALITY 07,27-87
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
FROM
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAPROP. 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.
(Sec. 3097, Civ. C.). SIDE '
P.L.
Lender's Name
7 3 LDMA Ref. #
Lender's Address P.C.Fee$ Permit Fee `, r
0 1 certify that I have read this application and state that the Issuance Fee �O.5Q LDMA P/C#
o above information is correct. I agree to comply with all County Investigation Fee 4``
0 ordinan and State laws relat' g to building construction, Total Fee 7 .vim LDMA Perm.#
6 and he b authorize represen -v this County to enter
upon t ve-mentio d pro 1 pection purposes.
;/(rr -2 SEE REVERSE FOR EXPLANATORY LANGUAGE
i nature of Applicant or Agent Date