HomeMy Public PortalAbout5310 ZADELL AVE_Building_12/8/1986_ V WORKERS'COMPENSATION DECLARATION
affirm that I have certificate of consent to self P P L I CAT N FOR WILDING PERMIT
insuresure,, or a certificate of Workers'Compensation Insurance,
or a certified copy thereof(Sec. 3800, Lob. C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- BUILDING i7
tion department. ADDRESS �J�D
Date Applicant CITY IP 7 LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT O �. I•-7 0 NO.Of NOW ON LOTS it NEARESTT.
COMPENSATION INSURANCECROSS
(This section need not be completed if the permit is for one TRACT dS� BLOCK LOT NO. ASSESSOR.
hundred dollars($100)or less.) MAP BOOK PAGE PARCEL
r �"
Y P OWNER P� RCp '""^'�`�^`�JO. � ZONE MAP
i certify that in the performance of the work for which this NO. 7
permit is issued, I shall not employ any person in any manner O ..I SPECIAL
so as to become subject to the Workers'Compensation Laws.
ADDRESS S3 CONDITIONS
Date l Applicant CITY A ZIP
NOTIC TO PPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE ESSED BY
ENGINEER NO.
Exemption, you should become subject to the Workers' CONST. ZONE
Compensation provisions of the Labor Code, you must forth- ADDRESS
with comply with such provisions or this permit shall be
deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. CONDO.
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATIONLIC, CLASS NO. 24 DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER P
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code,and my license is in full force and effect. CITY CLASS BK PG v VALIDATION
SQ.FT. NO.OF Q NO.OF P CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
� VALUATION
Contractor Date DESCRIPTION OF WORK -2oX NEW ❑ i i
ADD $ (�
I am exempt under Sec. /D �?ti
ALTER
❑,
B.&P.C. for this reason oZ0 REPAIR ❑, $
Dot USE OF DEMOL
EXISTING BLDG. ❑...
Sinneture _ APPLICANT �^ /� TEL. FINAL
OWNER-BUILDER DECLARATION PRINT)�tl l L L�JVL1, NO. DATE
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS 0 a FINA
Professions Code): PRESENT3 a By
BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and c
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). 'MOVING TEL. lool
I, as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- 6 U 7.7 A
tion 7044, Business and Professions Code). ADDRESS
REQUIRED YARD HWY TOTAL SETBACK FROM T. # 0 0 o a o
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH _
I hereby affirm that there is a construction lending agency for FRONT o o78.00
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
o P.L. 0 0 0 7 8 C U
t Lender's Name _v LDMA Ref. # t' 208-86
3 P.C. Fee$ Permit Fee • -�
Lender's Address
I certify that I have read this application and state that the Issuance Fee / L LDMA P/C 8
above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction,
i and hereby authorize representatives of this County to enter Total Fee -7ov, LDMA perm. #
upo the above-mentionp#property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Elate/ O i