HomeMy WebLinkAbout0217Am
a
a
WORKERS' COMPENSATION DECLARATION
I hereby affirm that. I have a, certificate of consent to self
insure, or a cortificate of Workers' Compensation Insurance,
or`a`certified copy 'thereof (Sec.' 3800,'Lob. 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 m the performance of the work for which this
permit is issued,'I shall 'riot employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after' 'nicking' 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,(evoked,
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 infull force and effect.
License Number. Lic. Class
Contractor Date
❑ I am exempt under Sec.
B.RP.C. for this reason
Date:
Signature
OWNER-BUILDFR DECLARATION
I hereby affirm that l 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).
19 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
ordi n b�yFtu
d State laws relating to building construction,
an he Ih�e tesentatives of this County to enter
u�gf(on t ee- en r d property for inspection purposes,__,
Signature of Applican€ of Agent Date
I L D I 06JOG PERMIT
COUNTY OF LOS ANGELES BUILDING .AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
€!
ADDRESS
r ;� . >•o:.
BUILDING
ADDRESS
CITY G- ( n u
ZIP e} f�
LOCALITYi-
SIZE OF LOT
NO. OF BLDGS.
NOW ON LOT
NEAREST
CROSS ST.
i /1
ASSESSOR
TRACT +,1.'� ,j ; _ ,�
BLOCK
LOT NO. :y "' : w�
MAP BOOK
PAGE
PARCEL
i F,
OWNER t;rA i cc
'i1�#
No NO. {? _: tj6
ON
f151 Z(
O.
f S v
I?
SPECIAL
"€,-
ADDRESS
:.
CONDITIONS .�
CITY Li4r. 6, L, 4-ZIP
617
ARCHITECT OR
ENGINEER
TEL.! Yf
NO. _ 6Co
DISTRICT
GROUP PE FIRE ROC SEDBY
CONS T ZONE
ADDRESS 3
CONTRACTOR
T
D_
STATISTICAL CLASS€FIC-4TION
A .
CONDO..
nnnoccc
LIC.
nin
CLASS NO
r '{ - DWELL, UNITS
SEWER I�AAP
LIC.
CITY CLASS
ZY
VALIDATION
SQ. FT. NO, OF NO.. OF CHECK
SIZE STORIES FAMILIES ONE
i 33
DESCRIPTION OF WORK I\ f E c« t v NEW
VALUATION
$ t
ADD
ALTER ❑
i " I
REPAIR ❑
USE OF
EXISTING BLDG. DEMOL ❑
i ,- +
APPLICANT j / _ TEL. '7� €
PRINT,U 7 �) NO y g y". 36F C+;
.
FINAL
DATE
/ / J qq
ADDRESS 'i �> u cy/L S f N ti t e CA J ��
FINAL
PRESENT
BY
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO,
ADDRESS
REQUIRED YARD HWY TOTAL SETBACK FROM ST. .
SET BACK PROP. LINE WIDTH ;
FRONT
P. L.
SIDE
P.L.
y -
Fee Permit Fee r
LDMA Ref. 9
P.C. $ .
Issuance Fee d f �'
LDMA P/C 9
lop
Investigation Fee c r
Total Fee
LDMA Perm. 1i
SEE REVERSE FOR EXPLANATORY LANGUAGE
' �r