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HomeMy WebLinkAbout9837ASignature OWNER -BUILDER DECLARATION I hereby affirm 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.). a Lender's Name Lender's Address I certify that I have read this application and state that the Q above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, u and hereby authorize representatives of this County to enter upon th jobove-m authorize, 6 )6rty for inspection purposes. g f= ` z }igna ure of pticant or Agent Da 1 WORKERS' COMPENSATION DECLARATION 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.) Policy No. Company EJ Certified copy is hereby furnished. QCertified copy is filed with the county building'Inspec- tion department. Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' 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, l shall not employ any person in any manner so as to become subject to the Workers�ompen n/1� �Date-4Applicant ` ' .0 NOTICE' O PLICANT: If, after -making this C ficate 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'Number Lic. Class Contractor bate I am exempt under Sec. B.&P.C. for this reason Date: USE OF EXISTIN APPLIC, APPLICA91PION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILD —,A ING AND SAFETY BUILDING FOR APPLICANT TO FILL IN ADDRESS 0Q)-,�aL�` BUILDING ADDRESS SIZE OF LOT TRACT OWNER �j� ADDRESS /7�'y0 CITY ARCHITECT OR ADDRESS CITY SQ. FT., SIZE DESCRIPTION OF OF ZIP 4P : LOCALITY NO. OF BLDGS, NEAREST NOW ON LOT CROSS ST. K LOT NO. AJDtbbUMAP BOOK PAGE TEL.NO.5= USE ZONE [SPENIALJ A OODITONS ZIP? y�1 TEL. ry DISTRICT GRO TYPE FIRE NO. �' OCT ZOt OF TEL. NO UC. NO me TEL. NO. Gt 2 STATISTICAL CLASSIFICATION" CLASS NO. DWELL, UNITS PARCEL APT 0 20C9SED BY F=- CONDO. SEWER MAP VALIDATION BK. PG. CHECK ONE a VALUATION NEW AT ADD 98-0, IA ALTER {`r s �, 0 ®6 $ REPAIR Fo �� 0 0 DEMOL 3% FINAL © �), 0 U Z) 1. 1 — - DATE ADDRESS 0i�&9i`�ft l�+✓ FINAL PRESENT By BUILDING ADDRESS LOCALITY '�-'�"- �� ��•��1.��_. � �" �I 7, 4 OIL FICIAi SE MOVING TEL. CONTRACTOR NO. I9 y LAURA S CERMAK ADDRESS NOTARY PUBLIC - CALIFORNIA 1 �� REQUIRED YARD HWY TOTAL SETBACK FROM EX ST. LOS A�IGELCS GOuN(f �, U SET BACK PROP. LINE WIDTH' My comm. expl es DEC 3 19 G �- .�-�� - . �- — J 0 C, } FRONT P.L. Q 1, 0 " ra 6 SIDE P.L. �s� y LDMA Ref. # P.C. Fee $ Permit Fee. �(f�✓ LDMA P/C # Issuance Fee Investigation Fee} � - Total Fee `'� LDMA Perm. # SEE REVERSE FOR EXPLANATORY LANGUAGE OQi