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HomeMy WebLinkAbout6519AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have o certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C. ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ® Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS a� ®Certified copy is filed with the county building inspec- BUILDING k s,`` $ $ ' f tion department. ADDRESS 7 c Applicant ZP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT.:-#' g"... NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one "g TRACT > "g BLOCK LOT NO. " ASSESSOR I Hundred donors ($100) or less.) MAP BOOK PAGE PARCEL TEL. OWNER, NO. US ONE MAP t certify that in the performance of the work for which this .,- f NO. permit is issued, I shall not employ any person in any manner SPECIAL so as to become subject to the Workers' Compensation Laws. ADDRESS:`1.-.fpu---; CONDITIONS — Ote CITY rs ZIP J i 0 Applicant k eF � Il I NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR p TEL w r§; ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY Exemption, you should become subject to the Workers' s. �; - r P a` ; A CONST. ZONE Ii Compensation provisions of the Labor Code, you must forth- ADDRESS $ tl, v, `<� �'s j� r with comply with such provisions or this permit shall be deemed revoked. TEL. CONTRACTOR NO. STATISTICAL CLASSIFICATION APT. LICENSED CONTRACTORS DECLARATION LIC. ACONDO. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO, (commencing with Section 7000) of Division 3 of the Business and LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS VALIDATION SQ. FT. NO. OF NO. OF CHECK BK. License Number Lic. Class SIZE STORIES FAMILIES ONE F '�. NEW ® VALUATION Contractor Date - DESCRIPTION OF WORK ;��' -� �-- ; ADD ❑ _ $ ElI am exempt under Seca -' ALTER B.&P.C. for this reason REPAIR ® $ Dote: USE OF EXISTING BLDG. DEMOL Signature APPLICANT x o s TEL PRINT) s. 3 ' ;i " OWNER -BUILDER DECLARATION NO..'- t �/� E` hereby affirm that I am exempt from the Contractor's License w for the following reason (Section 7031.5, Business and ADDRESS-:. °` °%z:-`i. > FINAL ofessions Code): PRESENT By f, as owner of the property, or my employees with BUILDING ADDRESS wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section tOCAUTY 7044, Business and Professions Code). MOVING TEL. ® I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY YARD }tWY SET BACK PROP. LINE WIDTH I herebyaffirm that there is a construction lending agency for g 9 Y FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P. L. Lender's Name LDMA Ref. # m Lender's Address P.C. Fen $ u�w Permit Fee w _ I certify that I have read this application and state that the Issuance Fee LDMA P/C # above information is correct. I agree to comply with all County Investigotior, Fee ordinances and State laws relating to building construction, Total Fee LDMA Perm. # i, and hereby authorize representatives of this County to enter upon the above -mentioned property for inspection purposes. M SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ©E To: PLANS TO APPLICANT Returned Approved Required Bate Received Yes No Approvals or Approved Water Cerlificate Health Department Fire Department Grading_ Geological Pedestrian Protection (Fence) (Canopy) Special Inspection (Conc.) (Masonry) (Welding) Lot Drainage Parking Inspector's Signature INSPECTOR'S NOTES OWNER-BUILIDER DECLARATION I hereby affirm that I am exempt from the Contractor's License taw for the following reason. (Sec. 7031.5) ,business and Professions Code. Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Con- tractor's License Law (Chapter 9) (commencing with Sec- tion 7000) of Division 3 of the business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any..violation of Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 05ON.): ❑ 1, as owner of the property, or my employees wlth wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044) Business and Professions Code., The Contractor's License Law does not apply to an owner of property who buil or improves thereon, and who does such work himself through his own employees, provided that such im- provements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that be did not build or improve for the purpose of sale). ❑ I, as owner of the property, am exclusively contrac- ting with licensed contractors to construct the project (Sec. 7044) Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law). ❑ I am exempt under Sec. , B.&P.C. for this reason Date Owner INSPECTOR'S NOTES