HomeMy WebLinkAbout9230AWORKERS' COMPENSATION DECLARATION _
I hereby affirm that I have a certificateC-ti'l
en t s finsure, or a certificate of Workers' CompeIn ra e,or a certified copy there fff (Sec. 3800, Lab
OF
Policy No-A�•�Company
❑ Certified copy is hereby fuWf�A❑ Certified copy is filed w'th'.{ht tl 1 s e4 D
tion department.
Datpplicant
CERTIFICATE OF EXEMPTION FROOppe!it
ERS'
COMPENSATION INSURA
(This section need not be completed if t 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.
r
License Number Lic. Cla
Contractor &--(— JwDate
❑ I am exempt under Sec.
BAP.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
Professions Code):
El 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
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances a to laws relating to building construction,
and her eb a one res tatives of this County to enter
upon tl ve- e property for inspection purposes.
IV Signa ure of pplicant or Agent Date
�
CITY
TRACT -
OWNER
ADDRESS
CITY l-...
i
APPLICATION FOR BUIL 1 E IT `
e
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING i1 FOR APPLICANT TO FILL IN ADDRESS �70VP Z.VA4,0/lai.
ADDRESS
CONTRACTOR
ADDRR� SS
CITY(, 01//!d
SQ. FT.
SIZE
DESCRIPTION OF
USE OF
EXISTING BLDG.
APPLICANT
(PRINT) /I
ZIP
LOCALITY
NO. OF BLDGS.
NEAREST
NOW ON LOT /
CROSS ST.
e
ASSESSOR
BLOCK LOT NO,
MAP BOOK
PAGE PARCEL
TEL. USE ZONE MAP 4 —
NO.
NO. O
SPECIAL
CONDITIONS
O
ZIP ��
U
TEL.
DISTRICT
I GROUP TYPE FIRE PROCESSED BY
0
NO.
CONS . ZONE
to 6,
lu
a
TEL._ /
® S ATISTICAL CLASSIFICATION APT, C DO.
tZo
LIC.
CLASS NO.
DWELL. UNITS
• 1!/404 4M D NO.
LIC. I '
CLASS43
"/
NO.OF NO. OF CHECK
STORIES FAMILIES ONE
DRK NEW ❑
ADD ❑
ALTER ❑
REPAIR ❑
DEMOL ❑
TEL.Q/��i�n
MOVING
CONTRACTOR
ADDRESS
REQUIRED YARD HWY TO'
SET BACK
FRONT
P. L.
SIDE
P. L.
P.C. Fee $ Perrr
Issua
Investigation Fee
Total
TEL.
NO.
a i d'-4; 0
� 3L
SEE REVERSE FOR EXPLANATORY LANGUAGE
BK, PG.
VALUATION ._
$
FINAL
DATE
FINAL
By
112
LDMA Ref. fi
LDMA P/C #
LDMA Perm. tf
VALIDATION
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O? .1
925.0A
o ® o c ® '1
2-261,60