HomeMy WebLinkAbout1326WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a ertified copy thereof (Sec. 3800, Lab. C. ' L
oil y No, �.•'�'` Company ` (/� ✓ 10-et,i
Certified copy is hereby furnished.
®Certified copy is filed with the county building ins ec-
tion department.
Date Applicant
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 Date
❑ 1 am exempt under Sec.
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
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
Q above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
d and h reby authorize repre nfatives of this County to enter
upo he above-menjjgne operty for inspection purposes.
Signature of Applicant or AgentU- Date
j
APPLICATION FOR
BUILDING PERMIT
J1-
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADDRESS
BUILDING e t ,
,_
ADDRESS
P
LOCALITY
O. OF BLDGS.
SIZE OF LOT - '_ OW ON LOT
NEAREST
CROSS ST.
TRACT BLOCK LOT NO.
ASSESSOR
MAP BOOK PAGE
PARCEL
,tt TEL. If
OWNER i .p € : . _ 1 6 d # iJ0. -, $-
USE ZONE NO.J
,f
ADDRESS � _ ;: 5 „ t' , d ?
SPECIAL
610 CONDITIONS
f
CITY
ARCHITECT OR TEL.
ENGINEER t L L,i 1 ' j14NO.
DISTRICT GROUP TYPE FIRE
CON L ZONE
PROCESSED BY
ADDRESS < k -E . k . 0 off .,
,,; `Z
TEL.
STATISTICAL CLASSIFICATION
APT. CONDO.
CONTRACTOR NO.
I
LIC.
CLASS NO. DWELL. UNITS
ADDRESS NO.
LIC.
SEWER MAP
CITY CLASS
BK. PG
VALIDATION
SQ. FT. NO. OF NO. OF CHECK
SIZE STORIES FAMILIES ONE
NEW ❑
VALUATION
-1 3 2 (j A
DESCRIPTION OF WORK j
ADD ❑
j
L-C ❑
ALTER
REPAIR ❑
USE OF DEMOL ❑
EXISTING BLDG.
7
" �'� R�. o O
G>
APPLICANT - TEL. e
'.NO.
FINAL
()'I 1i a
PRINT) C z E:.
DATE
ADDRESS e _, C t i
FINAL
PRESENT
By
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
h
ADDRESS
REQUIRED TOTAL SETBACK FROM EXIST.
SET BACK YARD HWY PROP. LINE WIDTH
FRONT
P.L.
SIDE
0.1P,
Ao
LDMA Ref. #
P.C. Fee $ Permit Fee
w }
Issuance Fee
LDMA P/C #
Investigation Fee
3 vo,! "
Total Fee
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE