HomeMy WebLinkAbout6290AWORKERS' 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, 2 r' �a om a �' 0040
--. Certified copy is hereby furnished.
❑Certified copy is filed with the county building inspec-
tion department.
Date Applicant_ Wee-�.�
RTIFI ATE 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.
Date Applicant
NOTIC 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 Number�✓ y / Lic: Class
Contractor s{/ Date 10
Errt7
❑ 1 am exempt under Sec.
B,&P.C. for this repson
D te:
Signature
WNER-BUILDER DEC ARATION e
I hereby affirm that I am exempt from the Contractor's License
l.aw for the following reason (Section 7031.5, Buslness 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 h reby authorize epresentatives of this County to enter
upon t e abov m nt' ned property for inspection purposes.
S �y
Signature of Applicant or Agent D to
1
APPLICATION FOR BUILDING ERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
'9%D
ADDRESS J
G Gi
CITY /X0~''C
IP
LOCALITY _
NO. OF BLDGS.
NEAREST
SIZE OF LOT
NOW ON LOT
CROSS ST.
r�
ASSESSOR
TRACT
BLOCK
LOT NO.
MAP BOOK
PAGE
PARCEL
USE ZONE
MAP
OWNER���
NO.
NO.
SPECIAL
ADDRESS
CONDITIONS
CITY _ JaA 1e -P441
ZIP
ARCHITECT OR f
TEL. 711A
NO.
DISTRICT GROUP I TYPE PROCESSED BY
ENGINEER.
f
CONST
0
&FIRE
ADDRESS f
�/'C r� ��
a
TEL.
STATISTICAL CLASSIFICATION
APT. CONDO,
CONTRACTOR
NO.
LIC.
CLASS NO. DWELL. UNITS
ADDRESS
NO.
LIC.
SEWER MAP
CITY
CLASS
BK PG
VALIDATION
SQ. FT. NO. OF
NO. OF CHECK
SIZE STORIES
/&,
FAMILIES ONE
a C7 ® NEW ❑
VALUATION
DESCRIPTION OF WORK
$�,
!mss
ADD ❑
ALTER ❑
6 2 9, a A
REPAIR ❑
$
23
USE OF
/ EXISTING BLDG.
DEMOL ❑
�
APPLICANTTEL. /
PRINT NO.
FINAL
7 IVr,
25 00
e')1
DATE 0
® 2"�: 006
ADDRESS
gr
FINAL
0226-87
BY
BUILDING
ADDRESS
LOCALITY
MOVING
TEL.
CONTRACTOR
NO,
ADDRESS
REQUIRED YARD HWY
SET BACK
TOTAL SETBACK F
PROP. LINE WIDTH
FRONT
� 6 2 9, 1 A
P. L.
SIDE
® o • m
P. L.
P.C. Fee $
(� (�
Permit fee �
LDMA Ref. #
o 5
u�)�
\� � 3
601130,500
�,
Issuance Fee tJ o
LDMA P/C #
0226 -87
Investigation Fee
�y
Total Fee . Z `t . 0
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE