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Home My Public Portal About5348 BUTTONS AVE_Building_5/12/1992_ (2)~ WORKERS' COMPENSATION DEClARATION I hereby off~m that I hove o certificote of consent to self insurl!, or a cerlificote of Workers' Compensation lnsurcnce, or dt.:ertified c~Pv.Jher~~f (Se.c·)soo! :Lo).'C.) !"-·I.· Policy No. (}/&;ij(. ComjJony·-':7;4·0~u,<~.c.<~~"-""""'-~- D ~e"rtified copy. i; hereby fUrnished. . · · 0 ·. Certified copy ts filed with the county,buildin9 inspec- • tion department.· · • Do~eY:./1z: f~ Appliconc60'-$ t" &'~ CERTIFICATE OF EXEMPTiON FROM woRJ<ERS:::=: COMPENSATION INSURANCE• ' . (This section need not be completed if the permit is fOr one hundred dollars {$100} ode~.) · · '. . I certify that in the performance. of the work "for which this permit is issued, I shall not employ any p'erson in any manner so as to become subject to the Workefs' Compensation Lows. Dot;§) B-q -z.Applicont Ro~a" C.:..J· , NOTICE TO APPliCANT: If, oftef"koking this Certificate of • Exemptign·, yoU should become , subje<:t to the· Wofkers' ·Compensation provisions of·th~e tabor Code, you must forth- with COf'I'.lply with such provisions or this permit shall be deemed revoked. • liCENSED.CONTRACTORS DECLARATION I hereby offirl'T] that I om licensed under provisions. of Cl?opter9 (commencing with Secti9n 7000} of Division 3 'of the .Business and Professions Code, and my license is in full force and effect Ljeen.se Number t{{(.t/1&7£ lie. Clo~'-Z.A._,__-7~ C~otroctorty"-ni ·0,.;,<:>\-Dote h-:!. l -:93 0 r om exempt under Sec·---''----------- S.&P.C. for this reason~· _____ _:__ ___ _:_ __ _ Dote: -;--:;;:c--'--... d'fr;un.·A·~ S1gnature ~~~ OWNER-BUILDER DECLARATION~ I hereby 'affirm that I om exempt from the Contractor's License low "for the following ~eos-on (Section 7031.5, Busipess ,end Professions Code}: . . · D l, os owner of the Property,. or m..;" employees with wages os their sole compensation, wi!l.do the work and the structure is not intended or offered for sole (Section ·•· 7044, ·Business aild Professions Code:) · · 0: ·!. as owner of the property, am exclusively contracting . · with ·licensed cOntractors to construct··1he project (Sec- t_ioo 7044, Business and Professions Code.) !=ONSTRUCriON LENDING .. AGENCY , I hereby affirm that there: is a. construction lerding agency for the performance of the Work for which this permit iS iSS"ued (Sec. 3097. av. C.). Lend~r's Nome-------.,-~--:-----~-.,. Lender's Address . . I certify that I have read this opPiicOtion and state th'ai the above information is correct. I og~ee to_complywith oiLCounty ordinances. and Staf.~)aws. relating _to ,bui!d_ing .construp{on, and hereby authorize representatives-of this County to enter (...... .... "f/!1 • ..... _, . AIP>!P>U<CA1i]©W FOJ~ _!B)QJJ~ILlCHINl~ !P>~~M~ll' . :: • • COUNTY O,F LOS ANGELES,. ' . - FOR APPLICANT TO FILL IN L'-"'AL! &~s ;k. ian: kA/A /U. ZIP BUILDING AND SAFETY. . ..('.:J.J/.F.. /_.__ ~- ~ - p '--O<M I /7 ' . . J. -1if?. ·-J lOCAl rTVC! ___.V~ ~___,.-..,.. ..,. ~ /"__:::;,_____.,-_.,... (I NO. OF BLDGS, NEAREST 7 ~ ~~~~-::;-"':::;;:::~0.:_ __ _cN:oO:,:W:..o:O:,:N'il:,:O::_T ____ • __ -_'-l CROSS ST. • ~~K PAGE ,Pt?f-- USE ZO':~ .;:) t{.S :] . f-j .. . ?;: 8 ·-0! · · CONSl . . DlSTRICT ~GROUP I TYPE I . FIRE P.ROCESSEO BY _ ZONE g ADDRESS "...§b,f . 3 v .3' -~ "' z STATJSTlCAL CtASSIFICA CONDO. • ClASS NO. ,;t I DWELL UNITS. SEWER MAP . • I ,-- CITY £K. I PG. 1/:1 SQ. FT. VALIDATION SIZE VALUATION $1~7 tP' ~ IT> I USE.OF . . $' I EXISTING BLDG . AP~~~~ , ~:~L 1_ r -1 ~ 1 FINAL ;J,~~ II By ~---.,_ ,_. , <r· -·r " ~7-K: (~ ... ':;"c •. ~,HQC"'-r- ' '-.l"-...,J.~!:-,~1 • • '· ··--:-t • \ _:_;; -.- ~ .. ~:~ :.-'"? ........__;., . . ~ .5,:.1.}/ . ~.:.\~"-"-'-r-~. "( '\ ~"'r· ~ \1'.7 . I :. ... .... ...... L~ i ~~~~~~T .. TEL .•. NO. "48,.'75 . [> tOCAlJTY 10~.~;~~~~: i\CC:T.* ADDRESS ' I . / -~.' ... --. .. r REQUIRED · YARD HWY TOTAl SETBACK FROM-· ' EXIST. '\ .. "":":' ... ~ , ... • SET BACK PROP. LINE WIDTH ,.,.~ • •. -.:-• . :_-.. • _ • ., --,-1':-l,-r FRONT '.],~~"{..:-~~ .• .-·~~,~·,It~ . ..,:~\·-;:.::., .l. l!':.t"l.:• Pl ' -·' •.:.,..,.,~ . .._:.....;o...\\ ......... •. '.. ···--< /""'~' ''·\"'·-·--" ~.-.' -;9' SIDE r. • "' -·~ _............... ·-· • ·h~H'!!... ...:J:u;.::tt-"';~_,. P:L .. ~ -\'. ; ' \.).. (' \.._, \ \\..,} ,.,,. . '. -::--< ~ ,~r-. 1 --··.).!.~·~\.'-\ .:}-<! •. -.'\•\ \~ !\.;f..\Et./~ ',_:,iJ-"I:ul.~7 /A7'7..,-1 . .. . 0{ :3o sc, LDMA Ref.#. , \ ,; r-H'·'''"'" ~0. / r::::J ~erfll!!__fee 1 ~ I~. .:1 '-· Hr1~:.:!i:._ l:s.suonce Fee ,:::2 J./: 7 S LDMA PIC # -· [> . . ' #o~ :\. ~: .. ~07 :!:'55"5":- P.'C. Fee .. $-~-.,, .,.oo Investigation Fee ---T "") f -_::; 1 1 • · .... -Total Fee C7"'.:;; 6, .:::J 7 .LDMA Perm. # 1}!]1]!}-l]l]!} 1 u.? ~ •h ob'!ve-mentioned PrOperty for irspecti~UfPoses. -. • ; ~4 . . . -1-~?-9/'.--. --· ... SEE REVERSE· fOR EXPlANATORY lANGUAGE 3308 1 51121'72 Af111~!)5 Signoture of Applic~nt or Age • Dote .'