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HomeMy WebLinkAbout4940AWORKERS' 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. 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 subject to the Workers ompensation Laws. Date �E�✓ ApplicantE� �r 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 ElI am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code). Lic. or Reg. No. Date 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 i 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 above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, ' and hereby authorize representatives of this County to enter upgn th above=men tgned property for inspection purposes. a � � Signature of Applicant or Agent Date I i ADDRESS CONTRACTOR ADDRESS CITY SCd. FT SIZE �� PERMITAPPLICATION FOR BUILD"ING COUNTYOF LOS ANGELES BUILDING FOR APPLICANT TO FILL IN ADDRESS E��` BUILDING ADDRESS 7 { s LOCALITY l0, NEAREST CITY a�Aa,, t. ZIP CROSS ST. . SIZE OF LOT f ; NO. OF BLDGS. C� C�4;`' NOW ON LOT �' ASSESSOR MAP BOOK PAGE PARCEL BLOCK LOT NO. ` USE ZONE J MAP7 NO. nr TEL, Zd 7"i SPECIAL OWNER } NO. - CONDITIONS DISTRICT GROUP TYPE PROCESSED BY FIRELAPT. ADDRESS ,� ( Y �. jL;J JCONST. r ZQf JE (' CITY (�,`+ @ ZIP STATISTICAL CLASSIFICATION CONDO. ARCHITECT OR TEL. ENGINEER NO. CLASS NO. cJ DWELL. UNITS OF I USE OF EXISTING BLDG. APPLICANT (PRINT) ADDRESS PRESENT BUILDING ADDRESS — LOCALITY MOVING CONTRACTOR ADDRESS TEL. -7o a 6 , &, , 0 O. LIC. NO. LIC. CLASS SEWER MAP BK. PG, V UATION G' $�� NO. OF INO. OF CHECK STORIES FAMILIES ONE Z-1 NEW ❑ $ DIRKE' ADD ALTER ❑ FINAL REPAIR ❑ DATE DEMOL FINAL B Y TEL. �d a A - , C .r>. NO. r,.- _ '? TEL. NO. SET BACK I YARD I HWY I TOTAL SETBACK LINE FROM I WIDTH FRONT P.L. SIDE P.L. BEEMEM P.C. Fee $ S< e) !Permite A -(3Fee .SoInvestigation Fee SEE REVERSE FOR EXPLANATORY LANGUAGE VALIDATION ©s