HomeMy WebLinkAbout0298AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate ofcikiim
se€
insure, or a certificate of Workers' Co d
s o In once
ar a certified copy thereof (5ec. '3800b.
n
Policy No, Company
❑ Certified copy is hereby furnished.;
-::
❑ Certified copy is file f�e 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 oft work for which this
permit is issued, I shall not employ person i ny ma er
so as to become subject tc the W rs' Comp "cition ws,'
y'
1 �r
Dote Applicant
NOTICE TO APPLICANT: If, cie.'making this Certific a of
Exemption, you should become subject to the W rkers'
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 fhe Business
and Professions Code, and my iicense is in full force and effect.
License Number Lic. Class
Contractor Date.
❑ I am exempt under Sec.
BAP.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
ro ssions 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
(5ec. 3097, Civ. C.).
Lender's Name
Lender's Addr s
I certify tho I have read his apphca
above. ,info atian is torr ct. I agree to
ordina6--y6 and Stafe )6ws relating to
and ho, y outhcriz representative
upon/ye,iovrrm96tioned prQpe f
Signature of Applicarl or
n nd state that the
ply with all County
uilding construction,
this County to ter
inspection u s
_ ll�al
Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
AuaowG
ADDRESS
L IN
ADDRESS
'
CITY
ZIP
LOCALITY
NO, OF BLDG5.
NEAREST
SIZE OF LOT
NOW ON LOT
CROSS ST.
ASSESSOR
TRACT
BLOCK
LOT NO.
MAP BOOK
PAGE
PARCEL
OWNER
TEL.
NO.
USE; ZONE
MAP
NO.
SPECIAL
ADDRESS -
CONDITIONS
CITY
ZIP
ARCHITECT OR
TEL.
DISTRICT GROUP TYPE
HIRE PROCESSED BY
ENGINEER
NO.
CONST.
ZONE
ADDRESS
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
VALUATION
DESCRIPTION OF WORK
NEW ❑
ADD ❑
3
ALTER ❑
t , F
REPAIR ❑
;
USE OF
❑
a • r • •
EXISTING BLDG.
DEMO L
APPLICANT
TEL
F •
(PRINT)
NO.
FINAL
DATE
ADDRESS
FINAL
PRESENT
By
BUILDING
ADDRESS
LOCALITY
Poll
TEL.
CONTRACTOR
NO,
ADDRESS
REQUIRED YARD HWY
TOTAL SETBACK FROM
EXIST.
SET BACK
PROP, LINE
WIDTH
FRONT
P. L.
SIDE
P. L.
LDMA Ref, #
P.C. Fee $
Permit Fee
►
Issuance Fee
LDMA P/C #
Investigation Fee
Total Fee
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE
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