HomeMy WebLinkAbout5593AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy. thereof (Sec. 3800, Lab. C. )
Policy No. CA1 1O 17 Company R . DU11114 fu CO.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date `l /27 /81 Applicant i)Il''R',1,TA TNT
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, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws,
11
Date R Applicant DTl T2T�it�T?TNT
NOTICE O_AP LICANT: 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.
2G 3724 1 U-1
License Number Lic. Class —
Contractor '01IaRI''1i1RI n Date 1 / 2 7 / 81
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic, or Reg. No. Date
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
�i 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).
❑ 1, 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 d912-11144"x PACIFIC
Lender's Address 334 D3.A !tOND BAR BLVD.
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes.
APPLICATION FOR. �ImILC�IN .
i COUNTY OF LOS ANGELESBUILDING AN'. SAFETY
FOR APPLICANT TO FILL IN ADDRBUILDING
ESS � �A
BUILDING
ADDRESS 2137 NI7 ?7 -'?' LOCALITY �•vC�(�
CITY DINT-IOND ?BAR, ZIP 91-�7/ 65 NEAREST
CROSS ST.
NO. OF BLDGS. — (_ -- ASSESSOR
SIZE OF LOT ciC NOW ON LOT MAP BOOK
TRACT' IBLOCK
OWNER P 1lir'+1111"1.Li.1. �`•! _r
ADDRESS
CITY ZIP
ARCHITECT OR r s + r
Ftir.ItiFKc r ED Oi.rZ.v.CEL
ADDRESS
ADDRESS
CITY
SQ. FTC iG r / NO. OF
SIZE 7" G+� STORIE;
DESCRIPTION OF WORK
� E'W COS151:
USE OF
EXISTING BLDG, — Q —
APPLICANT PZT.;M D
PRUANI Zr,
BUILDING 1
LOT NO. n USEtZQN� NOP / G .� J J
TEL. y ' / SPECIAL
NO. 5 9 4— 2 5 1 CONDITIONS
DISTRICT GROUP TYPE FIRE
�Q
CONST.'�" ZOF�./
1 STATISTICAL CLASSIFICATION
`92—.5 c'v CLASS NO.651' Z DWELL. UNITS
SEWER MAP
TEL.
�n NO.
UC
NO.
LIC
NO. OF
CHECK
FAMILIES
ONE
NEW Q
O'`J
ADD ❑
ALTER ❑
-
REPAIR ❑
DEMOL ❑
TEL.
594-20
LOCALITY
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP, LINE
EXIST,
WIDTH
FRONT
P, L.
SIDE
P.L.
��77
P.C. Fee $ �Cf' ��
Permit Fee
Issuance Fee
investigation ree
Total Fee
ACEL
i
IOCESSED BY 1
APT. CONDO. 1
_g
a
VALIDATION
VALUATION
$
$ 9. ' A3
r
FINAL • • �" L �i
DATE l ° 520.80
FINAL
By •'° 5 2 wl b'-i
01,27`81'
r
SEE REVERSE FOR EXPLANATORY LANCAIAGE
Signature of Applicant or Agent Dale)