HomeMy WebLinkAbout1449AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a itified c y ther of ( 3800 b. C.)
Policy 0-0 llo1 p— ny
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
EJ de artment.
Date' Applicant
RTIFICATE 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.
late Applicant
)TICE TO APPLICANT: If, after making this Certificate of
cxemption, 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 Numberr �-7Lic. Class s
Contractor � Date
&/�✓ _` 'R
I am exempt under Se %
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
1--)fessions 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
m 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
S ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
m up heja�bove ention property for inspection purposes,
Signatur of Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING
BUILDING �j � �jy`�r B �y ADDRESS �y
ADDRESS //ia % 3& 7 11 (.�/W! � (�Ll \ r C 1,--l.,,� V6N A
SIZE OF LOT
TRACT
OWNER Ir
CITY
ARCHITECT OR
ENGINEER
ADDRESS I'g2,0
CONTRACTOR
ADDRESS
CITY' d/�L.
SQ. FT. NC
SIZE I ST(
DESCRIPTION OF WOR
/t tt
USE OF
EXISTING BLDG.
BUILDING
ADDRESS
LOCALITY
MOVING
�A__¢(r't ZIP
NO. OF BLDGS.
NOW ON LOT
)CK LOT NO.
coTEL. / i,'
�f%' % No. '
-fi g TEL. (' e
LOCALITY
NEAREST
CROSS ST.
ASSESSOR
# MAP BOOK
C%Ildf/1 USE ZONE
TEL..
NOI,C(,L
LIC.
CLASS
OF
:IES
NO. OF
LIAMILIES
CHECK
ONE
NEW
ADD
ALTER
REPAIR
DEMOL
3
/3
TEL.
NO,
TEL.
NO.
iET BACK YARD HWY
FRONT
P. L.
SIDE
P. L.
P.C. Fee
Investigation
Permit Fee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
NO.
SPECIAL
DISTRICT I GROUP
ATISTICAL CLA IFIC?
C
CLASS NO.
SEWER MAP
BK. PG.
VALUATION
DQS
FINAL
DATE
FINAL
By
LDMA Perm. #
I PAGE I PARCEL
FIRE KPROC4ESSED
ZONQ4
APT. I CONDO
UNITS
VALIDATION
1 (J. [I.9 A
a.e �27
1$e2a00
e 2 5%0{.,�U
09,08-8 8
45C)A
X
�
09,08-88
OWNI"R43Lfil.DIHA DECLARATION
I hereby,offirm that,I. am exempt from the Contracts's
License Law for ,the folIow.rng, reason:; (Sec,;,,
Business and 7'rofessii dos t✓ade ' 4:ni crty,'ri7 crrui tu`ti'dyich
t•eyuirc:s a permit to construct,'altrrt', itvrptor>r deiraolulr,
or repair un y structure; prrnr to its assuatsce, also require s
the applicatot for such Pe rniit ''M file is signed strt'"tentertl
thatbe is licensed pursuant to :The provi.sions.of the C r»i
tractor's License Lau, (Chapter 9)(ci>itarri+tit►c`iroq;u.+itb S.
tion 7000) of Division 3 of the Business and Pa tr ession.s
Code) or that he is vxe4tpt tdserefrona anc dtr bars`is for t i
alleged evemptian,' Any vrratattron of Srctiort 11131.5 by
any applicant' or a perniit stabjects !hv applicant to a civil
penalty"of not tore ibdif fine hi nFltnrl'drsClats ( D(i j^
[_ 1, as owner of the property 'or my employees with
wages as their solecompensation, will do fhe:work, ,end
the structure is not infended-or offered! for. sole:(Sec:•7044)
Business and Professiota3 Ccide;,Tbe Coostructor's E,icemte
Lau- does not apply to an ou-ner of properly who builds
or improves thereon, and a-ho does such work himself,
through leis "oum employees,?' prarrided' that `'srl h 'm
pro cements are :not intended or "offered for•'sQl0if
however, the &:sildinX or ttnprovemcnd %rsold tcrtfsIn one
gear of completion, the oioner.braildet„ tt il!• fida+e tv
burden of proving that he did,not build or improi e jnr
The. purpose of sale).
❑ 4, as owner of the' property,,arn exclusively controc,
Ling -,with licensedcontractors io construct the project (Sec.
7044) t1lusiness and PrnfMiotss Coif Thv Contractor's
Lice'4si Lau, does not a/rply to_dn owttaz of properq,uY hri
fiu9lds or.'ilnproves thereon, and uho agotcacts for such
pr�r!o)ettts t�tJtlt tt contructrasJicarised p'faYsLant to, the
y?�,-onleactSrs, License Lalt) ,. _...i
[1 I am exempt under Sec. , F3.&P.C,.,for this
reason
Date
WSPEiT 'S NOTES
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