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HomeMy Public PortalAbout5703 OAK AVE_Building_6/15/1987_JIVORKERS' CC�APENSATION DECLARATION I F},4by aff rgivthot 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.) Policy No. Company ❑ Certified copy is hereby furnished. j Certified copy is filed with the county building inspec- tion departInent. 7 Date Applicant &RTI CATS OF EXEMPTION M WO E S' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Nu er � .3 lic. On— / l Controcto Dote 1:11 am exempt der Sec. B.&P.C. for this reason Date - Signature OWNER -BUILDER DECLARATION I hereby off irm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have re this application and state that the above information ' c rect. I agree to comply with all County ordinances and a aws relating to building construction, and hereby ou or representatives of this County to enter upon tkm obo e- r inspection purposes. e�mis Applicant or Agent f L)CIPF APPLICATION FOR. BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN 10 BUILDING�'` I ADDRESSr�7 / .3 aale 6��a CIZIP NO. OF BLDGS. SIZE OF LOT NOW ON LOT TRACT I BLOCK ! LOT NO. TEL OWNERN611'3 -09 ADDRESS// CITY �yy .�` ZIP ARCHITECT OR TEL. ENGINEER NO. ADDRESS / TEL. CONTRACT �r%�_ N&U2- S-11 LIC ADDRESS -z? �.z 8r�-371 �/r LIC. CITY CLASS SQ T. NO. OF NO. OF CHECK SIZE ISTORIES (FAMILIES ONE DESCRIPTION OF WORK USE OF EXISTING BLDG. APPLICANT (PRINT) TEL. NO. BUILDING J%©� ADDRESS / LOCALITY NEAREST % CROSS ST. ASSESSOR MAP BOOK PAGE USE ZONE MAP n KSPE I SPECIAL I CONDITIONS DISTRICT GROUP TYPE t 0y' 9�� CONST. I STATISTICAL CLASSIFIATION CLASS NO. 2 DWELL. UNITS SEWER MAP BK. PG. NEW ADD ❑ ❑ VALUATION $ ALTER ❑ NO. REPAIR ❑ $ DEMOL ❑ LINE WIDTH FRONT FINAL SIDE ?1/DATE �7 CC!! P.L. LOCALITY MOVING TEL. CONTRACTOR NO. ADDRESS BACK YARD HWY SETBA TOTAPROP.FROM SETT LINE WIDTH FRONT P.L. SIDE P.L. P.C. Fee $ Investigation Fee Permit Fee Issuance Fee Total Fee 2 �C SEE REVERSE FOR EXPLANATORY LANGUAGE LDMA Ref. # �V D. P/C # �U LDMA Perm. # PARCEL FIRE PR CESSED BY ZONE APT. FCONDO. VALIDATION 00, ;9724,8A # 0 0 0 0 0 1 A a o28.50 0615-87 5- 0 O O U LU CL fn z - i Z o a • - �. cn -n to m Q �' � m CD CD ' T _ A U T n3:fl t(9 QCT 3 tQ t0 ,_ t13 b - =_� v t a Lo 0 CD Q 7c a I'D Qt4 O tom? 3 W Q° C o O crO An Q � v 2 a'„ N _ ID Q13 �O vi 0:0 0.0 C6 ' r� ^ . , i .•,r. -• dry. K � 4 y CD' 3^ Lam" ,vt tD O r^i S ^ "' fi `J �• 3` r` r l •y"' % O "S `.. �' _ w. >r y .. '` 4 rad w. tQ to EQ .� SO RT- ra C ^t " fin' O w. !0 1t cs �q to Ll O "iats ,-� ^ • �r � �" ! •„ .tl• ^ `ti 'M: !`` '' �' N w .".� '.wt M .�. !w +0 '+ n 't "`v} - .,+ Z .,.+ ir • h, N .v ',,,. T. r •'•-., n K .. �••`-y ''�' ��"',, �_ fD O .0.. `" ""�• •�•�' � :n q' K " 't O � .�+ - 3 - ���.. `. �' ii �' wZ �r.1 A' SKr ,N•. 1 �' "J w. fS wC�.a. 'S � K '`. .•ems � ,il+ • ►�yy v }�j7 t/� �1 ~y (D 0` �+.. h •a' y h` _ w. +V ..� V .7 j•�y ++� K R ry iii `a' "`1 :/1 MCt r�. `_"'� .a �•..� �+ ? �- per.,, �' � � � r � � � �� � � � �• � '� w y � �. -s. ,� � � � •;• CL fn CD @ L;. `S O- C �S .� _ ,�.,Oj G % t�n`i O %' t~'�} .w. Tei' :t .+ O to "�" C qi K '^It ft, r 'o v w. © 1y. h V !• ca !4f1 m .,. tiG. „ o tin _,'y '» H 'CS O . { . y� `" A n «'' 7r � ^. n n O