Loading...
HomeMy WebLinkAbout5936Am v m 0 U Q Q a .vORKERS' COMPENSATION DECLARATION aeby 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 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' Compensation Laws. ➢` Date �JL—Y� Applicant_ 'OTICE TO APPLICANT: If, after making this Certificate of emption, 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 QI 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 Prof ions 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 - Lion 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 (See.: 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 ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above -mentioned property for inspection purposes. 0(0 Signature of Applicant or Agent Date PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING ADDRESSBUILDING ADDRESS � s' �, R.tin:' >, rc CITY rm= � ZIP LOCALITY �l (c ii /M �%ir`� 1 .a NO. OF BLDGS. NEAREST SIZE OF LOT NOW ON LOT CROSS ST. ASSESSOR TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL OWNER NO x USE ZONE MAP TEL 8� NO. !s G7 CITY 1P'x< `.. ZIP c ARCHITECT OR, ,. r TEL j" ,Fr rs y ENGINEER NO, ADDRESS fia TEL7 CONTRACTOR �"�t < NOri9e LIC. ADDRESS,2gL�49 L2, X1,,t NO. -- '� CITY UJ ' LIC. CLASS SQ. FT.a e NO. OF NO. OF CHECK SIZE STORIES v FAMILIES ONE DESCRIPTION OF WORK NEW C ADD C ALTER / REPAIR E USE OF EXISTING BLDG, DEMOL C APPLICANT TEL. (PRINT) NO. ADDRESS DISTRICT GROUP TYPE FIRE CONST.I ZOI` 10 STATISTICAL CLASSIFICATION CLASS NO. DWELL. UNITS SEWER MAP BK. PG. VALUATIO $ FINAL DATE FINAL By LOCALITY MOVING TEL. 100. CONTRACTOR NO. REQUIRED TOTAL SETBACK FROM EXIST. SET BACK YARD HWY PROP. LINE WIDTH FRONT P. L. SIDE P. L. .'� LDMA Ref. # C. Fee $ P ( Permit Fee 3. Issuance Fee / 0 ' 1 LDMA P/C # vestigation Fee Total Fee ! LDMA Perm. # SEE REVERSE FOR EXPLANATORY LANGUAGE APT �,® I, 0 fsP ,SED BY U UJ CL NDO. Z VALIDATION 9 [)8) © I