HomeMy WebLinkAbout1079AWORKERS' 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 No. -Company -
Certified copy is hereby furnished
® Certified copy is filed with the c i
Lion depart
men .
Date W i � Applicant
my buildjnA inspec-
CERTIFICATE OF EXEMPTION F OM WORKERS'
COMPENSATION INS RANCE
(This section need not be cornplef d if the permit is for one
hundred dollars ($100) or less.)
certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
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 -� f Lic. Class
ContractorfJ,,° IAj/ Date
I am exempt under Sec.
B.&P.C, for this re son
Date:
Signature
OWN R-BUILDER DECLARATION
Hereby afflr�m that am exempt from the Contractor's License
jw for the fol-lowing 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 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
w I certify that I have read this application and state that the
a above information is correct. I agree to comply with all County
$ ordina "' s and St to ows relating to building construction,
u and h ;eby ouf!?onz representatives of this County to enter
up�u,n a above- tioned property for inspection purposes.
r� Signature of Applicant or Agent Date
COUNTYAPPLIC."ATION FOR BUILDING PERMI
OF LOS ANGELES BUILDINGAND SAFETY I
TO FILL IN
BUILDING
ADDRESS
BUILDING
�)�d da
¢ ,-,
t3 f 7`-v
LOCALITY
r �'�ADDRESS,
CITY ':., r�0 -f.l
ZIP t 16' .
NEAREST
CROSS ST.
7AANANT
NO. OF BLDGS.
ASSESSOR
SIZE OF LOTNOW
ON LOT
MAPBOOK
PAGE
PARCEL
°
USE ZONE
MAP
TRACT
LOT NO. p
NO.
yTEL.
,_,�,"-,')1 / l o-^
NO.. f t °d
SPECIALOWNER
CONDITIONSDISTRICT
GROUP TYPE FIREPROCESSED
BY
ADDRESS )�f 1
•, ` G
CONS ZONE
CITY
ZIP
TEL. d
STATISTICAL CLASSIFICATIO
APT. CONDO.
ARCHITECT OR �`
ENGINEER r`' IC..
�`!
CLASS NO. DWELL. UNITS
ADDRESS /-41Y,` —i
CONTRACTOR P1 spy! f -d•'41
TEL.
NO
LIC.
e'C NO
LIC.
CITY
SQ. FT. NO. OF NO. OF
SIZE STORIES FAMILIE
DESCRIPTION OF WORK
X 1 5'u'E has f'_50,--•%
16_;p
9
CHECK
ONE
NEW
ADD
ALTER
REPAIR
USE OF DEMOL ❑
EXISTING BLDG.
APPLICANk TEL. 4
ESS
NT
ING
ESS
LITY
NG
TEL
RACTOR
NO.
[PBD
ESS
UIRED
YARD
HWY
TOTAL SETBACK FROM
EXIST,
BACK
PROP. LINE
WIDTH
NTee
$
Permit Fee
Issuance Fee
Investigation Fee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
JtWtR MAP
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VALIDATION
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