HomeMy WebLinkAbout1060AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, lab. C.)
Policy No.; ; C / .: Company ..�.
Certified copy is hereby furnished.
Certified copy is filed with the co n y-building inspec-
tion department.
Date Ap
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, 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 Dole
I am exempt from The licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my profossio al. capacity (Section 7051,
Business and Professions Code).
Lic. or Reg --No. i Dole
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low 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 properly, am exclusively contracting
will) licensed contractors to construct the project (Soc
lion 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. I.
tender's Name
lender's Address
I certify Ihot I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and Sate Taws relating to building construction,
and hereby u size, representatives of this County to enter
upon Ihe,.ab entioned properly for inspection purposes.
r
Signature of A'r?5"Mbr Agent Date
COUNTY Or LOS ANGELES BUILDING AND
FOR APPLICANT TO FILL IN
' BUILDING
BUILDING
ADDRESS 2 J �Ci ' U t p G '� N' )
)"� �6 � n
/ •f. r r.
LOCALITY / a� >l% �
CITY )jl\ `\JtJ�j 11�1- r , I ,A ZIP
NEAREST
�' CROSS ST.
�• _ n
`y
NO. OF BLDGS,
ASSESSOR
SIZE OF LOT NOW ON LOT
MAP BOOK
PAGE
PARCEL
I I r �1(,.
USE ZONE
MAP _
')
TRACT]
BLOCK
LOT NO.
NO.
SPECIAL
OWNER c�i_Il yl l l! Ot '•�I.L.( F�!,T hN�% TEL
��..L'� •"
CONDITIONS
DISTRICT GROUP TYPE
FIRE
PROCESSED BY
ADDRESS 17� %' (/ L- L\ir_ f�lY' /j )._( l�fi
C�NSi
ZOt
1 ,'1 /ti { It' 111. ZIP i ? k(1
CITY
-
STATISTICAL CLASSIFICATION
APT, CONDO
ARCHITECT OR TEL.
ENGINEER it r' �1 l I fZ !K NO.
n
CLASS NO. -' n DWELL UNITS
ADDRESS L ', t! l.) +\L Ns '1 tl (, r i U :`/ I fJ
SEWER MAP
TEL.
BK, PG,
VALIDATION
CONTRACTOR NO,
LIC.
H
ADDRESS NO.
- VALUATION
LIC.
1 C• b' 0 A
CITY CLASS
$
SQ. FT. NO. OF NO. OF CHECK
v
SIZE STORIES FAMILIES ONE
�\\ l , !r•��,,
1 If F P n
1
DESCRIPTION OF WORK NEW
ADD
AtTFR
FINAL
1 I. I•, .;
REPAIR
DATE
EJ
USE OF
DEMOL
FINAL
❑
EXISTING BLDG.
x B
y
APPLICANT TEl `'
(PRINT) l .yl '( L'/\ IQ NO. )7W .O,4L
REACT CAREFULLY
!• '• � n �,.�) 1 1, bl V 7
ADDRESS 7_ " 1 L` f� r
THIS APPLICATION IS A BUILDING
= PERMIT WHEN PROPERLY FILLED OUT.
SIGNED, AND MACHINE VALIDATED
1 ( C/ CA
I NI
FOR THE CORRECT PERMIT FEE IN THE
BUILDING
ADDRESS
VALIDATION SPACE, PERMISSION IS
f' ® ®I w�
THEREFORE GRANTED TO DO SUCH
p C:
LOCALITY
WORK AS INDICATED IN THIS APPLI•
CATION, IN ACCORDANCE WITH, AND
+ ® ®E-, 4• U C
MOVING TEl
SUBJECT TO ALL OF THE PROVISIONS OF
CONTRACTOR NO
THE BUILDING CODE, ORDINANCE
C
x2221, Of HIT COUNTY OF IOS
ADDRESS
ANUI I L S, AND Rf I A 11 D LAM
REQUIRED TOTAL SETBACK FROM EXIST.
YARD HWY
SET BACK PROP. LINE WIDTH = THIS PERMIT BECOMES NULL AND VOID
I1 [-
0 6 0 t` ! 8
FRONT
IF WORK IS NOT COMMENCED WITHIN
A
'1
120 DAYS FROM THE DATE OF ISSUANCE
OR If WORK IS SUSPENDED AT ANY
SIDE
TIME DURING CONSTRUCTION TOR
® ® • 0 a 1
MORE IHAN 120 DAYS, OR If ANY
WORK IS DONE ON IHE SAID AOH DING
( e r Q
/ %
I, T\ \
OR STRUCTURE IN VIOLATION OF ANY
P.C. Fee $ �7� [' '� Permit Fee /,
COUNTY ORDINANCE OR STATF LAW
RETATING
(� /� r
l l/)Issuance
THERETO
Fee`
A ROAD DEPI PERMIT IS PFQU1RED FOR
O
C4 C' 6 o
t�
Investigation Fee I
� �1
�'
ANY MATERIAL 570RACrf QR WORK.
L
Total Fee I
DONE IN THE ROAD RIGHT OF WAY
SEE REVERSE FOR EXPLANATORY LANGUAGE