HomeMy WebLinkAbout5558AWORKERS' 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.�Q any—�
Cer ified copy is erefurnishe`d.
❑Certified copy is filed with the county building inspec-
tion department. f
a
Date Applicant �� Y, x
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($)00) 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.
Aicense Number `�"'� � 2— y� � Lic. Class
� xclGarcSl "
Contractor E- �/Z �Z Date
❑ I 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
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
3
0 1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County
0 ordinances and State laws relating to building construction,
o and hereby authorize representatives of this County to enter
a upon ab ve-. entio _ roperty for inspection purposes.
113
Signo u of Applicant or Agent Date
COUNTY OF LOS ANGELES
PERMIT
BUILDING AND SAFETY
FOR APPLI ANT TO FILL IN
ADDRESS
BUILDING,
ADDRESS /Z/ eq z 1-7.
CITY �'✓ p�5 ZIP
\
LOCALITY
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
NEAREST
CROSS ST.
TRACT BLOCK LOT O.
ASSESSOR
MAP BOOK
PAGE PARCEL
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OWNERTOt %I
USE ZONE MAP
ADDRESS ✓ � r; �± ,
NO.
SPECIAL
fe 7
CONDITIONS
CITY !mot ZIP
ARCHITECT O TEL
ENGINEER cut 1
DISTRICT GROUP TYPE
FIRE PR ESSED BY
ADDRESS I`?
"`t- CONST.
o � t*;�._�yf �_.
ZONE
.
TEL. C%
CONTRACTOR G C2 r t�i NO. O
STATISTICAL CLASSIFICATION
APT. CONDO.
ADDRESS % �y 1 LIC N�
CLASS NO. ? DWELL. UNITS
"�-�( f
E)'i V ), �
`A °
SEWER MAP
CITY t 1 t } ) p LI ASS
BK.
VALIDATION
SQ. FT. NO, OF NO. OF CHECK
SIZE STORIES FAMILIES ONE
DESCRIPTION OF WORK NEW ❑
VALUATION
^��`- ADD ❑
ALTER ❑
REPAIR ❑
;
USE OF
EXISTING BLD . DEMOL
( r
APPLICANT TEL.
PRINT) O•
FINAL
'
DATE
O
ADDRESS
FINAL
PRESENT
By
BUILDING
ADDRESS
" 17)
LOCALITY
MOVING TEL,
CONTRACTOR NO.
c
ADDRESS
REQUIRED TOTAL SETBACK FROMw003"��
SET BACK YARD HWY PROP. LINE WIDTH
FRONT
I
P. L.
"
SIDE
P. L.
P.C. Fee ``
LDMA Ref. #
-
$ e Permit Feed
Issuance Fee 4 but
LDMA P/C #
Investigation fee �
Total Fee
���
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE
VIP,
t p P7, by t bra pGCkw% sionature
F
Pnli Oil "wnt
I hereby offim, that I am exemp, burn Mr, Whocwr`s
License Law for the following reason. (Sec. 7031 . '))
Business and 1;roless;Oras Cody; ff Pa I, oily or I 1, 1 ut! ich
rvqUAYS a purnoft in cow"Va ayn
or rupWraRv shwetury Prior in Q Asnance, Mo mqahv�
de appKaw Q such permit to late a Qj4ed sho'ement
that he is Ucenvedpunvant to fbe pinnWhas (I The Qm
tractors IAWWV law (Cbaplev 9)(coraanaencaea ; avid" 5ec-
An 70OW of MAW 3 Q& BuQw* tar Vroks&w
Code) or that be is o,,AH1'c1 therelropa and ibe, basis/,n- dw
alleged exemption. "Iny violation of Section 7031,5 I'l,
ally applicant for a 1wrllrif Tulrjee/s (be appfifar'i to a cioil
penal", o/ not Ynore than five dolho's (S' 500)'):
L! 1, as owner of Ma property, or my ernid6yees w0h
wages as their sole con-Denswion, will do lhe"Nwk, and
the structure is not intended or offerecl for sale (Sec 7044)
Business and PrQje-.,,ssions Code; 77ye Contra tor'' J,icense
Law does noe alrpllv to all owner of property wbn bl0d%
or iosproves thereon, and uhn dwK such woth hhmeq w
W"Rh has num employces, provided lb,ci sl,,,b
provements are not intet'dod or offvreff for' sak" ff,
however, Me bmilding or improvemene h svhF uMd, one
"t'ear of COmplofi)nl the OU'Wc-b'!'Id('r, ha` (' $be
burden rli"proving that be XO aw QWY onWP—for
the Purpose of sale), ,
El 4 as owner of No Ixoprolo uni axcluMvely contras
ting wnh licensed contractors W consm, We Poled Per-
7044) Business tired Pvi�,fvssions Codv: Tbe (,onyroclor",v
Lkeme Law does noe mpl)fv to an owner ollVc�periY -l-
bpililds or hoproves, fberoon, and mho c"emcig for sm-h
projects with a coutractor(v) ficeiesed pvrsuleme to the
Contractor's icease Last,),
I am exempt under Sec.-_--, K 811C W"Ms
Date
INSPECTOR% NOTOS