HomeMy Public PortalAbout9227 WORKMAN AVE_Building__ • t WORKERS'COMPENSATION DECLARATION
} I I re, o affirm that I have certificate of consent to self APPLICATION F R BUILDING I T
•
insure, or a certificate of Workers'Compensation Insurance, ® P�'��
or a certified copy thereof(Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
ElCertified copy is hereby furnished. R APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- gUILDESSINGQ ADDRESS
E] tion department. ADDRESS
�Y°�l /efjy� •� `
Date Applicant CITY JA�✓ i p /ZIP i 8 o LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' 01 NO.OF BLDGS. NEAREST fir %7-)
SIZE OF LOT afl�l C� NOW ON OT Z CROSS ST. ,�
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT' BLOCK LOT NO. MAP BOOK PAGE PARCEL
4, TEL, r USE ZONE MAP
I certify that'in the performance of the work for which this OWNER y A—L47- NO 1'f �` NO. (l
permit is issued,I shall not emplo any person in a anner `� SPECIAL
so as to be me subject tot ore 'Compe n L.
ADDRESS y BVI CONDITIONS
1 U.
Date Applicant CITY 9'l�sf ZIP !7 O a
ARCHITECT OR;U,,, TEL. ✓
NO T APPL NT: If, after making this Certificate of DISTRICT GROUP TYPE FIRE P CESSED BY Q
Exem tion, you should become subject to the Workers' ENGINEER �*Z" V1 NO. "L� �^ 7 CONST.\ ZONE U
Compensation provisions of the Labor Code, you must forth- ADDRESS �i(i
with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIF�CgTION APT. NDO. a`
deemed revoked. CONTRACTOR �" NO. U/ - ) z
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.—DWELL.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 and LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK L—. PG./ VALIDATION
SQ.FT, O.OF NO.OF CHECK
License Number Lic.Class SIZE �, STORIES FAMILIES ONE
VALUATION
DESCRIPTION OF WORK NEW
Contractor Date / ADD s ,
❑I am exempt under Sec. omti'4C ALTER
El//'+
B.BP.C. for this reason '8 jo T USE OF REPAIR ❑ $
Date: EXISTING BLDG. OR DEMOL ❑ ! 9 7-5 9.1 A
Signature APPLICANT TEL. �j FINAL # o o•o o 2 3
OWNER-BUILDER DECLARATION PRINT f✓��I NO.� —Jfl lC} DATE
1 hereby affirm that I am exempt from the Contractor's License �i I ° 5'8,1,4 0
Law for the following reason (Section 7031.5, Business and ADDRESS 6t" FIN ° 0 5 81.4 05
Professions Code): PRESENT By
❑ BUILDING 4 8 7
I, as owner of the property, or my employees with ADDRESS 0 8 0
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). MOVING TEL.
I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- gDDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK F
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT 8 fl 7 2
the performance of the work for which this permit is issued P.L. #,o o X
(Sec. 3097, Civ. C.). SIDE I - 694,50
` P.L.
Lender's Name '�✓� LDMA Ref. N 6 9 4,5 0 c=i
P.C.Fee$ J Permit Fee I' Q 0 7—8 7
Lender's Address
I certify that I have read this application and state that the Issuance Fee V (/ LDMA P/,C N
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee if LDMA Perm. t1
hereby authorize repr ntatives of this County to enter
upo he above-menti rope
for inspection pur oses.
g s �
o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ppiicant or Agent to i