HomeMy Public PortalAbout5301 ZADELL AVE_Building_4/13/1988_ 4 WORKERS'COMPENSATION DECLARATION
II
P APPLICATION FOR BUILDING PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) I
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
( A C G..
❑ Certified copy is filed with the county building inspec- I BUILDING
ADDRESS 5,30 Q►%!(-
tion department. ADDRESS S Q f, .A If a'
Date Applicant I CITY 1 EW1 LC_ d t C ZIP 7 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' 7 / NO.OF BLDGS. / KaLYS,i NEAREST G LV L
COMPENSATION INSURANCE I SIZE OF LOT NOW ON LOT I g=jm CROSS ST. fIK+ use al "1}
(This section need not be completed if the permit is for ones BLOCK LOT NO. �� ASSESSOR
hundred dollars($100)or less.) I TRACT MAP BOOK jj PAGE PARCEL
TEL.
USE Z E L
1 certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner ADDRESS ASAVC so as to become subject to the Workers Compensation Laws. ONS V
Date 3 ���Applicant Rc�A'�►� �- �V�'S CITY S 9 ZIP
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT ROUP I TYPE FIRE PROCESSED BY O
ENGINEER NO.
Exemption, you should become subject to the Workers' (� 7 CONS,T./ Z0* V
Compensation provisions of the Labor Code, you must forth- ADDRESS V W
with comply with such provisions or this permit shall be Ll:
deemed revoked. CONTRACTOR ' STATISTICAL CLASSIFICATION APT. CO Z
N
LICENSED CONTRACTORS DECLARATION I LIC. CLASS NO. 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 P
Professions Code, and my license is In full force and effect. I CITY CLASS BKS VALIDATION
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEVA �❑ $ O d li
ADD QJ 011111.❑I am exempt under Sec. l a� Tso LI}15, QJ�L
t . V ALTER E]B.&P.C. for this reason 1 7- 2-0Q L REPAIR ❑ $
Date: USE OF
EXISTING BLDG. 1A JSF" DEMOL ❑
Signature APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT 1 GE{b Lu NO. L DATEq i
I hereby affirm that I am exempt from the Contractor's License ADDRESS S 3'v� Z A4L. Sifr�
Law for the following reason (Section 7031.5, Business and FINAL 9 3 3 A
Professions Code): PRE N By
BUILDING k�� • # o o a o o 1
I, as owner of the property, ormy employees with ADDRESS
wages as their sole compensation,will do the work and 1 0 0 ,3,100
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. 0 0 0 3 3 0 0 05
❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS o 4't, 3-88
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
REQUIRED
BACK YARD HWY TOTAPROP.L NE WIDTCK FROM H
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 t—¢J LDMA Ref, #
Lender's Address P.C.Fee$ Permit Fee /fir
1 certify that I have read this application and state that the Issuance Fee !/t/ ) LDMA P/C# Poo
2 above information is correct. I agree to comply with all CountyInvestigation Fee
ordinances and State laws relating to building construction, Total Fee 3 /a�
V LDMA Perm. H
d and hereby authorize representatives of this County to enter
$ upon the above-mentioned property for inspection purposes.
3._99 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date