HomeMy WebLinkAbout8156AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
nsure, or a certificate of Workers' Compensation Insurance,
or a certfied copy thereof (Sec. 3800, Lob. C. )
Policy Na. T"�Company
__
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
ate Applica i
CERTIFICATE OF EXEMPTION FROM W RS'
COMPENSATION INSURANC
(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
"TICE, you should become subject to the Workers'
TICS TO APPLICANT: If, after making this Certificate of
mptio
ompensation 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 � �z^� Lic. Class
Contractor A/=Date
t am exempt under Sec.
Y 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
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County
0 ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the of a -mentioned T;zper�forspection purposes.
Sign Applicant or Agent Date
APPLICATION FOR
BUILDING PERIMIT
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
APPLICANT TO FILL IN
BUILDINFOR
ADDRESS
ADDRESS Si
BUILDING
ADDRESS
t
CITY � C _ i.„ gd'°- ZIP
ENO.
LOCALITY
OF BLDGSBLDGS.
SIZE OF LOT NOW ON LOT
NEAREST 3'
CROSS ST. t
TRACT
BLOCK
LOT NO.
ASSESSOR
MAP BOOK
PAGE
PARCEL
�" TEL.r R.a
OWNER r_ "" C¢ NO. E- �
USE ZONE
�P .7
ADDRESS ,� 0 ca a ` r
SPEC AL ,
CONDITIONS & s
CITY ° 6 &x O_� ZIP
ARCHITECT OR TEL _ .
�. � A_NO.
DISTRICT GROUP TYPE FIRE PROCESSED BY
z,
ENGINEER o
f<, ONST .. ZONE
ADDRESS Via? yes'
TEL. P�
"'m'
STATESTICAL CLASSIFICATION APT. CONDO.
CONTRACTOR NO.
0
LIC: e°
ADDRESS
ADDRESS ., ��� NO. e
CLASS NO, DWELL. UNITS -
goonsiomm
? LIC.
SEWER MAP
CITY ikP4�e— ,. CLASS &
BK. PG. VALIDATION
SQ. FT. NO. OF NO. OF CHECK
5iZE STORIE5 FAMILIES ONE
r ti ®: _... a -r
VALUATION
USE OF
EXISTING BLDG.
APPLICANT
(PRINT)
ADDRESS
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
REQUIRED YARD HWY
SET BACK
FRONT
P. L.
SIDE
P. L. AC
P.C. Fee $ s_
. /
Investiaation Fee
TEL.
NO.
Issuance Fee
Total Fee .
SEE REVERSE FOR EXPLANATORY LANGUAGE
0
91
LDMA Perm. #
i
F:
Tn.
Date
PLANS 10 AV'PUCANT
Ap rp ro v aas
y s No
ri
r e n, (C. brio,)
JF'
m
(-i o m e
Intrrlol
Lctn -Exte
ar�
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Or ApprovvA
MSPECTOR'S NOTES
OWN R - B U I E 1) R ICI C, 1, A W A x0N
I hpr-�Fry ciffwrn I'iar I cirri frorn the Cowr(i�'Iof's
1, r e -) s e Lu vl f o r the olloµnng r er-j,, o r jSeL 703 1 5)
req v iiv.% a 13 co nL% rri ct. riftcr, i Wr i I C , cdearvr,Nsb,
r I P' P'pri. i'"Fl a vp '
f13C 'VI"J77'Y'Pai a slahmcni
that be is jicvnsc,dpirsijani P, Vb(i PrM43iilFee r3f 1`11C (,")7?-
I pvc tw- 's 1, kvrd!;d' La w ((,baptvT' 1)) (cop?wen 4-; U,q u ljel.r -� (.v-
ti,)n 700(1) raf f)jvj.sjrrn 3 o/ tj,e PrFWcssyon.s
Old(") or e"'af be is vxevnp? arad fbv r",'Jtiisfor P/.?e
ellleqrd exengplion. Any vh;lalion o./ 9eceiem .20i L.bi-
applL an e ¢or a 1,elwyig svbjve fs the apIrlicein t to, i c, i
o/ nal more eban fiw bvnored dolkw.%
1, as awn(F Of the, propern/, or my ter-nployeewith
wages as their 50!0 te>mpe-nsotroA,1I1 ?he nr iirid
the !,Irudurc is no-. intended or offcredl for (se -. 7044�
Business aml pr-o[cuionv Grade: 177,� ty 'd t'e" icp.mv
Luu, dovs br4ilds
;mp?,;,vvs tkvremn, and vzho cl,,,us sacs � blm,�fff w
h "I ilis nva ra v sm
provemonts cwg rgl)t bfetl'qrj,!d tc?W—vd
howet,vr, of- gs
.-,zv,zr o/ wv-bawv the
bwdiga ojpvrjmps,� flr4re be di,i "l? f,jtild or lel'v
pt4rjloso fr!
o,lri(,r of 0he pmpL'd�, ur, E,)4, li,,,, v-111, r, I.- n
�wg vi i#v licensed _ororactors c- tlr,;F proveC, iSe-c
7(1,14 gyjsjtp��" an ,' P-ofessiow; xi= 'Fbet rat fir an _v
I'al", dorno"aji�w15'1P 'u- "/, pr,;1)e7!V wbo -
hu:Alg oinpr4w<--s tbf�l-eon, and d. jr. cove-a4s /;v ve;, 1.)
1"cense Law),
i orrl exef-rlw Ljnd,2r F, &P,C, Fm ?Errs v.
Date,