HomeMy WebLinkAbout8237AWORKERS' 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
.Company
Certified copy is hereby furnished.
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
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 subiect to the Worker ' Co �enFW_
L
Applicant
'OTICE TO APPLICANT: If, after making this Certificate of
emption, you should become subject to the Workers'
vompensation 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
Contractor
I am exempt under Sec,
B.&P.C, for this reason_
Lic. Class
Date
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):
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
(S3c. 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 he y authorize represent 'ves of this County to enter
upon ab "e-mend ed pr p ty for inspectio pure ses. (�
Signature of pplicanf or Agent Date
•
COUNTYOF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESSr~,.
BUILDING o
ADDRES
LOCALITY
r
CITY f d V ZIP
NO. OF BLDGS. ry
Ll 7
NEAREST
SIZE OF LOT NOW ON LOT l�G�
CROSS ST.
/S
ASSESSOR
TRACT U
BLOC�Kp LOT NO.
MAP BOOK
USE ZONE MAP
� ( NO.
PAGE
PARCEL
C.
OWNER I �/�� L' NO. EL
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ADDRESS " L /✓
ttg° r9 CONDITIONS
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CITY `` C%/�iia, ZIP(
DISTRICT GROUP
TYPE
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FIRE PROCESSED BY
ZONE
ARCHITECT OR yam/ f TE Zf3 N
ENGINEER 1!C r— NO.�//
a ^'
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ADDRESS I
-
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STATISTICAL CLASSIFICATION
APT.
C DO.
CONTRACTOR dt�W n Cl NO. �S"
' )
CLASS NO.
DWELL. UNITSIRMO
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ADDRESS ��09 5*° J ��= NC)_ «� (�
CITY L t r�� q CLASS
SW,'W) ISTOROS SIZE /GX�V7 I AMILLIIES
DESCRIPTION OF WORK'j�(,{�iF! �ri9
USE OF
EXISTING BLDG.
APPLICANT Z 2� N ^
PRINT / 1 p /
ADDRES,lx2 �'` l� �x-��
1-2
PRE E
BUILDING
ADDRESS
MOVING TEL.
CONTRACTOR NO.
P. L.
SIDE
P.L.
C. Fee $
SEWLR MAP
BK. PG,
CHECK
ONE
VALUATION
NEW
$ �S C✓ C
ADD ❑
ALTER ❑
REPAIR ❑
$
DEMOL ❑
ry_
FINAL
_
DATE
FINAL
BY
VALIDATION
J' £ ), , t { ., z c
YARD HWY 4Fee.:3
-nio,.
WIDTH
h
,.:.1: i A
r
p7�LDMA Re# o s
��R�, LDMA P/C #
11.
Fee fig.. 0rf�
Total Fee / f LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE