HomeMy WebLinkAbout3640AWORKERS' 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, r 7 Y 1 t 7`Codpany
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date Applicant 'a: -ar,
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.
1
License Number L f Lic. Class _
Contractor' # "' kc a„ ;!Date'—
I am exempt under Sec._ r
B.&P.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low 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
a 1 certify that I have read this application and state that the
a above information is correct. I agree to comply with all County
S ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
mup n tir, above- ntioned property for inspection purposes.
PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDING
BUILDING FOR APPLICANT TO FILL IN dry y
ADDRESS
ADDRESS 11 13 i3l "A &C1 7 IT'
p ik L' %
CITY A (� � ZIP C i LOCALITY
NO. OF BLDGS. NEAREST ;
SIZE OF LOT NOW ON LOT CROSS ST.
ASSESSOR ' ,
TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
OWNER E � R . r Ep USE ,,ONE MAP �
d!! SPECIAL
ADDRESS CONDITIONS
[DESCRIPTION
Y ZIP
CHITECT OR @t� ( r / TEL -y`� (e6
GINEER NO."'�"DRESSTEL.
NTRACTOR NO. `3°1 e'
let
0.
¢DRESS- WC-
Y (� r7l CASSA
. FT. NO. OF NO. OF CHECK
E STORIES ��}} FAMILIES ONE
OF WORK /� ( I ATC 1,%' i,,jftl NEW 10:�J]
USE OF
EXISTING BLDG.
APPLICANT JA0 A eLk ruki
(PRINT)
ADDRESS
PRESENT
BUILDING
ADDRESS
LOCALITY
MOVING
ADD
ALTER
REPAIR
DEMOL
DISTRICT
GROUP
I TYPE
FIRE
PROCESSED B'
CON T.
ZONE
mA
STATISTICAL CLASSIFICATION
APT.
CONDO.
I
CLASS NO.
DWELL. UNITS
SEWER MAP
FINAL
By
TEL. 100.
NO.
SET BACK
YARD
I HWY
" 1L .0
FRONT
P.L.
SIDE
P. L.
P.C. Fee $
C, z r Permit Fee
Investigation
Total Fee
LDMA Ref. #
P/C #
ti C 1 LDMA Perm. #
7
VALIDATION
I
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