HomeMy WebLinkAbout5022A (17).pdfWORKERS' COMPENSATIONDECLARATIONa r• '
insure, or aicertifcate of Workes'rificCompensaton Insurance, APPLICATION FOR SBU-ILDING PERMIT-._....... I,
Poli No Coma'
00 .C.) .... .. ... .. ..._ p .. . ,, . or h certified co th r f ci 38
ClvM' ,^',4tOq COUNTY OF LOS ANGELES BUILDING AND SAFETY j
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Certified copy is hereby furnished:
Cerfified copy is filed with the county building ins pet -
tion department
tD6te.1(%S Appl tak
CERTIFICATE OF EXEMPTION hOM WOK S^ - -
L COMPENSATION INSURANCE
This section need not be completed if the permit is for one --
hundred dollars ($100) or less.)... ..
certify that in ;heperformanceof the work for which this -
permit is issued, 1 shall notemploy any person in any manner
so as 'to become subject to the Workers' Cbmpensatiori Laws.
Dote Applicant'
NOTICE TO 'APPLICANT! If, offer making thisCertificate of
Exemptfon,,'•you' should become subject"to'ihe' Workers' -
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this,permit4 shall be ----
deemed revoked- 4 ,; ,.
LICENSED CONTRACTORS DECLARATION ,
1 hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, a((
nJ dd }my license ism full force and effect.
License Number.lLL1l
Q _
Lic Class
Contracto m• , 1 Dote ` it ` -
1 am exempt under S ----
B.BP.C. for this reason
BD RR - DECLARATION _ OWNE
Thereby affirm that f am eex pf from the Contractor's License
Law folr
tahs
owreason (
Section 7031.5, Business and
Professions Code: followingner of he property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sole (Section
7044, Business and Professions Code). - _-- -'
I, as owner of the property, am exclusively contracting
with licensed contractorstoconstruct 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 State laws relating to building construction, . .
C; -and hereby authorize representatives of this County to enter
n t e a ave- e i a rty for inspect" u p
FOR APPLICANT TO FILL IN
AunowG
ADDRESS 'a„
1BUILDING 'i 't / • I V'd1ADDRESSVU!
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CITY 1Q ZIP LOCALITY F
NO. OF BLDGS. NEAREST.___._.'
SIZE OF LOT NOW ON LOT CROSS ST.
TRACT BLOCK LOT NO. ..-
L
ASSESSOR..
MAP BOOK t r PAGE PARCEL
OWNERVI&OV 1' U NO S•O"l } USE ZONE MAPPLO. . i
pL SPECIAL -..
ADDRESS.. .. CL t, i J U....._ . .-: CONDITIONS
CITY
ARCHITECT OR
ENGINEER TEL. NO. DISTRICT - GROUP TYPE I FIRE. -,I PROCESSED BY .
ADDRESS J
A/
CONTRACTOR uT. , TEL. C.NO. STATISTICAL CLASSIFICATION
1 ' CIA55 NO. DWELL. UNITS
APT. CONDO.
L, - LIC. - - -
ADDRE )U%f aC NO. I 3
1'Q.j..._ .. _._ LIC. - C-3
SEWER MAP
cITY anss BK. vG, ._ VALIDATION.
SQ. FT. _ NO. OF NO OF _...1.
CHECK
SIZE STORIES FAMILIES ONE
wvnan
i ' QDESCRIPTIONOFWORK - Y" - NEW E]
ADD_ [:],
ALTER
v
L \ i _ .... _
REPAIR.. s . __... _
iUSEOF Lts& EXISTING BLDG.
Fi"ALAPPLICANT- NTT .Q, 1 ftc(
DATE'7-
j{'l rysILIAhh C P U 1`0 ''lr bJADDR( FINAL
T 5022A':
ADDRESSADDRESS I
e s a 1 '
e 1 49..25
LOCALITY'
MOVING-._ - _.-. TEL.• _ _.. - _ .:
CONTRACTOR NO.
ADDRESS
d 1• .8 ` 8... REQUIRED - - TOTAL SETBACK R _ IHWYSETBACKYARD. PROP• LINE WIDTH
FRONTPA
SIDE
LDMA Ref. A
I
QL^ZPermitFeeJl1
Issuance Fee . LDMA P/C A
Investigation Fee
Tocol Fee .. .. .. LDM4 Parma. N.-_.. .... t.._
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1 - _ a SEE REVERSE FOR EXPLANATORY LANGUAGEV"Iff--
Signature PPliconl or Agent --- Date - - - - -
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