HomeMy WebLinkAbout0015AWORKERS' 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
QCertified 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' 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):
® I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
o the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
® 1, 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
d ordinances and State laws relating to building construction,
R and hereby authorize representatives of this County to gnter
upon the above -mentioned property for inspection purpUbs,
a
Signature of Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL-IN BUILDING
e ADDRESS U' .i I /LCRLA Vj Y C
BUILDING O -3�
ADDRESS ` @@
CITY �aw�e�d f,R. ZIP Jr LOCALITY
NO, OF
SIZE OF LOTAGY" NOW ON LOTS -,or
CROSSSST. 4 �.
r CI'
�b�� BLOCK LOT NO, ASSESSOR
TRACT
MAP BOOK ' PAGE PARCEL
OWNER cITTv (,i!/j t yr N0,7L S2 w U 1E NO. r1 cl 3 .-7
ADDRESS a.5 5 C t► s l- SPECIAL
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CITY 614A ZIP
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ADDRESS I M �AP CMGSQ ► m 81% Ci
STATISTICAL CLAS/SIFIICgTION APT. rNDO, 0 '
C' TRA NO.
LIC, CLASS NO. '� DWELL. UNITS —
ADDRESS NO,
LIC. SEWER MAP
CITY CLASS c1f VALIDATION
'` NO, OF NO, OF CHECK BK. L PG.
SI `t STORIES �- FAMILIES t ONE
DESCRIP ON OF O cam' G1 d VALUATION
1
NEW . $
ADO u / s
_9U01,5A
ALTER Q
REPAIR ❑ $ # e, o s e 23
E OF DEMOL ❑ 1 1.1 51.33
EXI TIN G.
APPI RINT v T FINAL
�,S3SC1►� IZd low ` ,;7 DATE � 1. 1,� 51, 3 3
ADDRESS , S S %.1.�
FINAL 07.21 - 8 B
BUILDING
ADDRESS
LOCALITY ,
MOVING TEL. ®® , �M
CONTRACTOR NO.
ADDRESS I
SET BACK YARD HWY T TAPRCTP, LINE WIDTH Qo �L
PRL.
ONT
SIDE
P.L.
LDMA Ref. tt m
P.C. Fee; Permit Fee q
Issuance Fee LDMA P/C M 1
Investigotion Fee (�
Total Fee LDMA Perm, M
SEE REVERSE FOR EXPLANATORY LANGUAGE