HomeMy WebLinkAbout6447A,PENSATION DECLARATION
I have a certificate of consent to self
.cote of Workers' Compenstion Insurance, or
..y thereof (Sec. 3800, Lab. C. )
Company
:ertified copy is hereby furnished.
�J Certified copy is filed with the 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
hundreddollars ($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
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
Lic. Class
Contractor Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).'
Lic. or Reg. No. Date
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):
1, 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
I 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
upon the above -mentioned property for inspection purposes.
Signature of Applicant or Agent Dote
COUNTY OF LOS ANGELES BUILDING AND SAFETY
smosommms�
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING ADDRESS 01Mv`V RN c''D
LOCALITY
CITY �: �1 M L� ZIP
NEAREST
CROSS ST.
t�' 1 �� NO. OF BLDG.
ASSESSOR I
SIZE OF LOT NOW ON LOTS
MAP BOOK
PAGE
PARCEL
TRACT �� 44
BLOCK
LOT NO. 4
USE ZONE
(�
`�
MAP
NO. ,2 ' --F.4
TEL r��,`
OWNER Cl--RL5Fb '� COt`tS C-NO.`�)J'"15)
SPECIAL
CONDITIONS
ADDRESS.2 2-�5(1
DISTRICT I
GROUP
TYPE
CONST.
FIRE I
Z9 g
_
PROCESSED BY
CITY$„yE� (C: ZIP
4 G
ARCHITECT OR TEL i`
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STATISTICAL CLASSIFI TION APT. CONDO.
ENGINEER W61-L NO.1
CLASS NO. �� DWELL. UNITS
IIIIIIIIIIJ
SEWER MAP
BK. PG, VALIDATION
ADDRESS I I . �. ft
CONTRACTOR t"�,��� ���'1 ' NO. � .'J 1 � �
.LIC.
ADDRL )Ti O. /�
VALUATION
$
EEMMMMF
LIC.
CITY LOj _ 102—L-CLASS
SQ. FT.
NO. OF
NO. OF
CHECK
SIZE
STORIES
FAMILIES
ONE
I
DESCRIPTION OF WORK ryCw ce)N ✓ T,
NEW ❑
ADD r_1
ALTER
FINAL 2 0 6)
�i e Z_ s J'r-/-:,,6 �s
REPAIR ❑
DATE
FINAL � r. { 1 t c° ;
By
�t ,? !� (I � 0
I �
USE OF/EXISTING BLDG. �Si �� �
DEMOL �
APPLICANT TEL. X1
(PRINT) L J Yy'•'��( �
1
'' -T
ADDRESS .. 6;(ZE A
f,>
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
� 0
a '�C
d a 1
ADDRESS
REQUIRED
ET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTH
P. L.
SIDE
P.L.
r �%
f�
P.C, fee $ <'4''<J «
Permit Fee
Issuance Fee
Investigation Fee
_
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
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