HomeMy WebLinkAbout8599AWORKERS' 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. Company
Certified copy is hereby furnished.
❑Certified copy is filed with the county buildinginspec-
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 too be me�js object to the Workers' ompensation ws,'%.
Date
'OTICE TO APPLICANT: If, after making thi Certifica 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
❑ I am exempt under Seca
B.&P.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License
Law for the following' reason (Section 7031.5, Business and
Proessions Code):
I, as owner of the property, or my employees with
4 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. ).
o Lender's Name
Lender's Address
I certify that I have read this application and state that the
a above information is correct. I agree to comply with all County
m ordinances and State laws relating to building construction,
v and hereby authorize representatives of this County to enter
,n upon the a yve-mentioned Rroperty for inspectigr5 pu poses.
Signature of plicant or A ent Date/
APPLICATION FOR
BUILDING
PERMIT
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESSBUILDING
r f
ADDRESS / C ✓�ZC ✓P.t
CITY�- f y--
LOCALITY 3' i
NO. OF BLDGS,
NEAREST
SIZE OF LOT NOW ON LOT
CROSS ST.
Wi °
�
TRACT-/ � BLOCK LOT N
-.
ASSESSOR
MAPBOOK'PAGE
PARCEL
/J TEL.
NECi `- NO ®�
USE ZONE MAP
= t'
ADDRfi (�ll�,
NO.
SPECIAL
CONDITIONS
o
I Lf
- Cd
CITY L %c 7T" ZIP
,
ARCHITECT OR TEL.
DISTRICT GRO TYPE
FIRE PROCESSED BY
ENGINEER 1 NO.
CONSL
ZONE
ADDRESS � �!
� �' �'
TEL.
STATISTICAL CLASSIFICATION
APT. CONDO.
CONTRACTOR NO.
40
4 — LIC.
ADDRESS s -
CLASS NO.DWELL. UNITS
NO.
'
SEWER MAP
CITY ®/f1 CLASS
BK. PG,
VALIDATION
SQ. FTe7 NO. OF NO. OF CHECK
SIZE �4 I STORIES FAMILIES ONE
DESCRIPTION OF WORK - /)/J NEW
VALUATION
�j
ADD ❑
$
ALTER
0 �' J
REPAIR ❑
$
j �, (1 �� �� i'
USE OF
DE L ❑
�:
EXISTING BLDG.
APPLICAN TEL
PRI � ✓ /7 / A/K -'�_
FINAL f
-t
� ' 419- '/z'i 6-0C✓�
DATE
P U ` J
ADDRES � i
FINAt� �,
�
PRESENT
lay _
BUILDING
ADDRESS
LOCALITY
1- 9Q,3R
MOVING TEL.
CONTRACTOR NO.
�tj 0 o c @ �
ADDRESS
0 0
REQUIRED TOTAL SETBACK FROM ST.
SET BACK YARD HWY PROP. LINE WIDTH
FRONT
P. L.
1 a,
SIDE
P. L.
-
P.C. � ��� 14i3 Permit Fee � °f} +
LDMA Ref. #
�Fee �$r
�✓�i '' Issuance Fee'
LDMA P/C #
Investigation Fee p
Total Fee r
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE
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