HomeMy WebLinkAbout5623AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or certificd copy thereof (Sec. 3800, Lab. C.)
Pcy'V G t` 4iCompany
ertified copy is hereby furnished.
Certified copy is filed with the c unty building inspec-
tion department. , ,/49 p
Date* Applicant
CERTIFICATE OF EXEMPTION FROM O E
COMPENSATION INSURANC
(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 `-t �a \ �_Lic. Class
Contractor !EfC`W QA- . Date
❑ I am exempt under Sec.
BAP.C. for this reason
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 `''
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordina s d State laws relating to building construction,
and he e uthorize representatives of this County to enter
upon th ve-menti ry property for inspection purp ses.
'S -1-1 ..g
Signature of A plic nt r Agent Date
PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING (j � yW t 1 A64) „� UMN
ADDRESS i`r CITY ZIP -y(0S
NO. OF BLDGS.
_
SIZE OF LOT C�C� " NOW ON LOT
TRACT 0 ?_& BLOCK /+
OWNER `�J GG J-A -V-1 LIVA ` NO.
ADDRESS 3 S �a
3 l ilf T T- G-Q� CK;
CITY `� ZIP
ARCHITECT OR TEL.
ENGINEER ���C� �gL NO-7
(jI \` q
ADDRESS 1 E',p�0 U' rl�'
�� V CONTRACTOR W%J T QZ
ADDRESS (pr G_ q _"i
CITY ll�A N ID
SQ. FT.
SIZE
NO. OF
STORIES
NO. OF
FAMILIES
DESCRIPTION OF WORK
z: T A % N I V\J G VQNC
NO. `1 1A
LIC NO. �� 9'-
LIC.
CLASS
USE OF EXISTING BLDG. 1�� l �NTI �
APPLICANT *\�q TEL
(PRINT) �� . RJJ NO,
ADDRESS (07 C l Tnik U PICAN�)
BUILDINGgZM J iiaM ',•ram A "0
ADDRESS � e-"\
__D k P-1 MBA U 4) 11A VZ
NEAREST
CROSS ST.
ASSESSOR
MAP BOOK
PAGE Pi
USE ZONE
IMAP
NO.
c) }
SPECIAL
CONDITIONS
DISTRICT
GROUP
TYPE
FIRE
CONST.
ZONE
STATISTICAL CLASSIFICATION
APT.
CLASS NO.
DWELL. UNITS
CHECK
BK. P
G. .
*
ONE
VALUATION
NEW
aaATION
yy
$
ADD ❑
c�
ALTER ❑
REPAIR ❑
$
DEMOL ❑
FINAL
DATE
FINAL
By
MOVING
TEL.
CONTRACTOR
NO.
ADDRESS
REQUIRED YARD
HWY TOTAL SETBACK FROM Eh
SET BACK
PROP. LINE WI
FRONT
P. L.
SIDE
P. L.
P.C. Fee $ / 3y,
JJ
Permit Fee G J s
/1) -t)
Issuance Fee '
Investigation Fee
/ 7 �/ -42
"j'
Total Fee
SEE REVERSE
FOR EXPLANATORY LANGUAGE
I'
LDMA Ref.
LDMA
LDMA
VALIDATION
4 r
1 // •
tlLI 1t i
,
/a kcb s� I
it,
k-I
�� �„�y _ ,fit. �" •. >> �}' �,
Yk
\J 0
lox
I I ��� •\• /, li pry, `\ •;; •�, _���-�. t" j_" 'r I
s . ,q r� 7 �' � � l��L � _ �: _.-_- � -_, �•.�;1 _ _�.:- -� ��, it
V �
o S
Q?
l�
owl
ILI-
= .
y N►J1N pd jJl /