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WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
a certified copy there{. 3800, L b. )
Policy No. � Company
l Certified copy is hereby furnished.
❑Certified copy is filed with the county building inspec-
tion department,
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKER'
I, COMPENSATION INSURANCE
{This ection 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 1 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, Floss
Contractor Date
I am a pt under Sec. mot"
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
Professions Code):
I, as owner of the property, or my employees with
wages as their sole compensation, Willi 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
ordinances and ate lows relating to building construction,
and hereby out orize representatives of this County to enter
upon the abov-mentioned p opgrt f inspection purposes.
Signature of Applicant or Agent Dat
Aor"PLICATIO"1446
COUNTY OF LOS ANGELES BUILDING AND SAFETY
BUILDINFOR APPLICANT TO FILL IN ADDRESS ,c�
ADDRESS d�
BUILDING
ADDRESS
LOCALITY
CITY % ZIP
NO, OF BLDGS.
NEAREST
o
SIZE OF LOT
NOW ON LOT
CROSS ST.
ASSESSOR
TRACT
BLOCK LOT NO.
MAP BOOK
I PAGE
PARCEL
OWNER
j
r NO.
USE ZONE
MAP
NO. a 1
ADDRESS
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SPECIAL
CONDITIONS
CITY t 4 ZIP
ARCHITECT OR
ENGINEER
TEL.
L.Ii N
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DISTRICT
GROUP TYPE
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FIRE PROCESSED BY
ADDRESS
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CONTRALTO
TEL.
L' NO.
STATISTICAL CLASSIFICATION
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APT. CONDO.
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ADDRESS '„ °® v `. NO. ! ,
CLASS NO.
DWELL. UNITS
CITY
LIC.
-� i A_ CLASS
SEWER MAP
VALIDATION
SQ. FT,
NO, OF NO. OF
CHECK
BK.
PG.
_ �� c� t
SIZE
STORIES I FAMILIES
ONE
DESCRIPTION OF WORK I
NEW ❑
VALUATION
§
y i'
ADO
ALTER ®
REPAIR ®
$
V
USE OF
EXISTING BLDG,
DEMOL ®
APPLICANT
TEL. q I
..I. �NO• 1
FINAL
S $
DATE
ADDRESS
FINAL
By
ADDRESS
LOCALITY
MOVING
TEL.
CONTRACTOR
NO.
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK
PROP, LINE
WIDTH
FRONT
P. L.
SIDE
P.L.
P.C. Fee
Permit Fee I T� o
LDMA Ref, #
$
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Issuance Fee ,
LDMA P/C #
Investigation Fee
�Oq(
Total Fee o
LDMA Parm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE