HomeMy WebLinkAbout2892WORKERS' 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 Nl&yg _Company
❑ Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department. %%�� T
Dates Appl1cani&921e "W /� l -Zi6
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, 1 shall not employ any person in any manner
so as to became subject to the Workers' Compensation 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.
License Number_ 10 f Lic. Class —
ElI am exempt under Sec.
B.RP.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 teason (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.)
ElI, 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
is
Lender's Address
0 1 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 authorize representatives of this County to enter
up the above-rnertion ..property for inspection purpose .
j Signature of Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING
FOR APPLICANT TO FILL IN ADDRESS
BUILDING
ADDRESS Yyl
CITY
SIZE OF LOT _
TRACT 7.Q5 Qi- BLC
OWNER,&/Q/�/%%/�.GEr
ADDRESS17/6Y 159,11e, r,
CITY
ARCPItTICT-Oit -
ENGINEER Z/410 i
ADDRESS
CONTRACTOR
ADDRESS ®�
CITY
SQ. FT. / NO. OF
SIZE S
DESCRIPTION OF WORK
_%q - .
USE OF
EXISTING BLI
APPLICANT
(PRINT)
ADDRESS
I��
PRESENT
BUILDING
ADDRESS —
LOCALITY
MOVING
CONTRACTO
ADDRESS
�11
REQUIRED
SET BACK
FRONT
P. L.
SIDE
P. L.
P.C. Fee $
Investiqation
YARD I HWY
ZIP
NO. OF BLDGS,
NOW ON LOT
—_ LOT I
TEL.
NO.
ZIP
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NO.
LIC.
NO,
LIC.
CLASS
NO. OF
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ALITY
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STATISTICAL CLASSIFICATION APT. I COOD(
CLASS NO. 02'0 DWELL. UNITS,
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ONE
VALUATION NEW s 4 V Gr
ADD ❑ ►
ALTER ❑
REPAIR ❑ $
DEMOL ❑
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FINAL
DATE
FINAL
By
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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VALIDATION'
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