HomeMy WebLinkAbout3604AWORKERS COMPENSATION DECLARATION
I hereby offirm.that I hope a certificate :of consent to self
ON Fow"I'll
`
BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800,Jab. C. } " '
�,.
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
Policy,No � Compan
•Certified copy is hereby furnish d.
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS7 CXS` �6.ai3✓i�� /P✓/'�.
'Certified copy is filed with the county building in'spec-
BUILDINGtp
ADDRESS
lion department
6
Date: 1 Appllcan,& fi t K z'l i
s
CITY � ZIP
LOCALITY �
CERTIFICATE OF EXEMPTION FROM WORKERS' '''
Na. OF BLDGS.
SIZE OF LOT NOW ON LOT
NEAREST j
CROSS ST. I>��/' %6✓/r
COMPENSATION INSURANCE
This section need not be completed if, the permit is for one
P
TRACT % �
BLOCK
J
LOT NO. J �
ASSESSOR.
MAP BOOK
PAGES
PARCEL
hundred dollars.($lt}0) or. less.). _.
_ TEL.
NO
USE TONE
MAP"
NO. (l"T
I certify. that in the performance of the work for which this
is issued, I employ any in any manner
OWNER' ar'�
�/dT A' �13��!
y A'
SPECIAL ,
permit shall.not person
ADDRESS3 1 '/ r 7 , �'°
CONDITIONS
so as to become subject to the Workers` Compensation Laws.
CITY e0Sr.q Ada �� ZIP ���9� t✓4
Date Applicant,
NOTICE TO APPUCANT:'.If offer making thls Certificale of
.
TEL.
ENGINEER GC�� �!/%NO.
DISTRICT GROUP
TYPE
CONST
FIRE
ZONE
PROCESSED BY
�3
:xempi€on, you 'should 'become subject to the Workers'
f9
Compensation provisions of the Labor Code, you must forth-
ADDRESS
with. comply with such: provisions or this permit steal be
p y .; p. }
TEL
STATISTICAL CLASSIFICATION
APT.
ONDO.
deemed revoked,'.
CONTRACTOR NO.
CLASS No. DWELL, UN17S
LICENSED CONTRACTORS DECLARATION...
— UC.
I hereby offirm that I am licensed under provisions of Chapter 9
ADDRESS NO,
SEWER MAP
(commencing with Section 7000) of Divisiofi 3 of the Business and
L€C.
VALIDATION
Professions Code, and my license is in, full force and offecl.
CITY CLASS
BK. PG
_, ; '"
Lic. Class
SQ. FT.
SIZE
Na. OF -.
STORIES
NO. OF
FAMILIES
CHECK
ONE
License1Numbor
Q � p
Conlracto /�1YY1lAf l°_lM_. Date. f ' -S`
DESCRIPTION OF WORK
NEW
❑
VALUATION
s L5
i am exempt under Sec.
t p/} / si
ADD
ALTER Q
"No
Q
$
B.&P.C. for this reason
1MLd1yqtMCQ
REPAIR
p te:
SE OF
EXISTING BLDG. VV-W,)
DEMOL Q
S€gnatu
APPLICANT TEL.
PRINT) Na. '-1 D�/
FINAL
DATE
i
ONER-BUILDER DECLARATION
W
I hereby affirm that I am exempt from the Contractors License
ADDRESS
FINAL
Low for the following 7eason.(Sec€ion 7031.5, Business and
By
Professions Code):
PRESENT
BUILDING
;
I, as owner of the property, or my employees with
ADDRESS
�
wages as their sole compensation, will do the work and
I '
the structure is not intended or offered for sale (Section
LOCALITY
7044, Business and Professions Code).
MOVING TEL.
NO.
I, as owner of the property, am exclusively contracting
❑
CONTRACTOR
'
- with licensed contractors to construct the project (Sec-
ADDRESS
tion 7044, Business and Professions Code).
REQUIRED
TOTAL SETBACK FROM
T.
CONSTRUCTION LENDING AGENCY
SET BACK
YARD
HWY
PROP. LINE
WIDTH'
I hereby affirm that there is a construction lending agency for
FRONT
the performance of the work for which this permit is issued
P.L.
(Sec. 3097, Civ. C. ).
SIDE
P.L..
o Lender's Name
j
r '
LDMA Ref. #
$
\
P.C. Fee $ x ,
Pesmii fee
Lender's Address
I certify. that I have read this application and state that the
Issuance Fee
LDMA P/C #
above information is correct. I agree to comply with all County
Investigation Fee'
75.LDMA
m ordinances and State laws relating to building construction,
Total Fee
Perm.#
and hereby authorize representatives of this County to enter
upon the above-mentione property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign lure of Applicant or Agent Data