HomeMy WebLinkAbout1582AWORKERS' 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
Certified copy is hereby furnished.
❑Certified 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, I shall not employ any person in any manner
so as to become subject to the Worker ' Compe tion 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.
�j 45
License Number _1 ` • Z Lic. Class
Contractor D A -N N" S Date r ayy
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
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,).
Lender's Name
Lender's Address
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 aut rize representatives of this County to enter
upon a abov - entioned property for inspection purposes.
AAA,,l ` 14— /D '
Signature of Applicant or Agent Date
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING% 5 j
ADDRESS
CITY
SIfa- ZIP 6117
LOCALITY r
.✓i d`
NO. OF BLDGS.
NEAREST
a
SIZE OF LOT
NOW ON LOT
CROSS SL
ASSESSOR
TRACT
BLOCK
LOT NO./
MAP BOOK
PAGE
PAR EL
P
TEL.S"A"D Aa NO.S l9 / 2So
OWNER
USE ZONE
MAP
NO.
2 f �j c g
, ?,q i �6
SPECIAL
ADDRESS D
J
CONDITIONS
CITY D tr`wwoQ
l2hit, ZIP ci 1111�g
ARCHITECT OR
ENGINEER
TEL.
NO.
DISTRICT
GROUP
TYPE
CONST -, ,_f54-
✓
FIRE
ZONE
PROCESSED BY
ADDRESS
TEL.STATISTICAL
CLASSIFICATION
PT.
CONDO.
CONTRACTOR rl �`-'
NO. �ip "SS
�r�
CLASS NO. DWELL. UNITS
Cr1>v
nYLS(7
2� LI
3 L-
ADDRESS
ori NO. (SqS
SEWER MAP
�,A LIC. c�
Q,' ON R _�
CITY
CLASS f
BK PG
VALIDATION
SQ. FT
NO. OF
NO. OF
CHECK
SIZE ZSt�
STORIES
FAMILIES
ONE
VALUATION
A"e— aVO"ORK
NEW
DESCRIPTION OF WORK
❑
ADD El
ALTER
$ � 3 U, v - tl0
/
REPAIR ❑
DEMOL ❑
FINAL
USE OF
EXISTING BLDG.
APPLICANT TEL.
(PRINT) NO.
DATE%
ADDRESS
FINAL
BY
PRESENT
BUILDING
"
ADDRESS
"
LOCALITY
MOVING TEL.
CONTRACTOR
NO.
I
ADDRESS
REQUIRED YARD HWY TOTAL SETBACK FROM
SET BACK PROP. LINE WIDTH
FRONT
P. L.
SIDE
P. L.
LDMA Ref. #
P.C. Fee $
Permit Fee �.
��
Issuance Fee 01 ,
LDMA P/C #
Investigation Fee
Total Fee 6,fl,
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE
INSPECTOR'S NOTES 0WN1-1*R43UJI.D1-,R DU*,CI.ARA*tJ0J14I
- -1 -_ -ript from Ihe,,4�ontr
1 hereby affirm that I am exei actor's
Li.conse, Law for the following. reason. (Seca 7031,.,S)
Business and Pro ssi(ihs(,r)dt,.,4n,vcityorcciundviobicb
PLANS TO APPLICANT 1 11 11
.11 .
70;
--------777777 I
ReturNed
Approved
No. Date
No. Date
requires a permit to const rucl-allm improve, demolish,
1
orrepaieanlstrucit�re,'P�i()'?I to its isvuance, lid wt requ!res
the applican t for such pernoit tin file a signed siatemen I
A ,
, �v - 1 1" ,
11, 1. . .
0
that be ds licensed pursuant to the e provisions of the
tractors License Law (C-hapter 9) (rantrosencing witbS c-
7 tion 7000) of Division 3 of the Business and Professions
Cade) or that he is exApt tbe'eefrotn and.tho basis for the
7,7
alleged exet?,piiorjh.',Any viWation"bf Section 1031,5 by
a", applicant fora permit subjects- tbo4plieant loacivil
n
pealo of nof"inore'than ./tae bioiotdred'drillars (9500))"
1, as owner of the property, or my employees with
wage.5 as their sole, cQ m pensatio ri, �,ydk:do the "WQr.kond
the structure is not intended e
v 7 - -A --I "! �" I, f -, � � " , . or offered for sale (Sec. 70")
a
Busineikand Professions Codex Contraefrors
P.
j q builds
_J to an ou-ner of &n( U
'o ru,44
. ..
Approvals
Reyu....... liedDate
Re ceived
or Approved
s
..No,
YVqjer Cerlificate
m
r un thereon, and who does sik �ntself or
11
through his' oujn,emplq�,ees, prortir4dea"thaPsuich'itfi.
Gr6bingve
pro Mona are not hirtendid o offered fae'��M'l jf,
%
kinuover, the biiilding or a stq. orn. one
),ear rof crirnpp etio the ;
"V)ner-buil er have the
burden qf proving that build or improve"
-4 the purpose
1, as owner of the propeorty;i am,exdusivel contrac.
4. "T Y
Yong with-hrensod contractors to construct 'the .protect (Sec,
teol
(Fence). (-Canopy)
5,
Inspection
(Conc. l (Masonry) (Welding)
61
11940.) 84#iness and Prqfqs��jyy -CipdR The Contractor's
se tau, does not -AA n_01w r of proper(( who
bul'Id r ipirproves {h {eon and, U- 1)(It -on�
�qcts for such
pirtijew tb a,: con Mdceri;��seV t4n-1 to, the
Contractor's License Law).
Lp� Drainage
Parking
lame xempi under Sec._ a, &P.C, for this
reason
Date Owner
INSPECTOR'S NOTES
pprovals ..
Date
Anspector's Signaftire
Locution—.
(Setback & Yard5)
Foundations
Slob
Frame
Energy Insulation
+
Lath,'Dfywoll—
Interior
Loth —Exterior
House Number
Correct & Posted
Final_
Enter on Front
Ay j —1