HomeMy WebLinkAbout1334A 1335A , � . y._.
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WORKER5'COMPENSATION DECIARATION - � �
I hereby affirm that I have a ce�tificate of�o�se��,o self qpp��CATlO�I� �F�OR� BUILDING PERMIT
insure,ar a certificote of Workers'Gompensation Insurance,
or a certified copy thereof(Sec.�3800, qb C) - � n
�,�„� C4UNTY OF LOS ANGELES BUILDING AND SAfETY �
PolicyNo.��� •�•� Company�� 6UIlDWG ���@' /%1 �
� Certified copy rs hereby fumished. fOR APPLICANT TO fILL IN ' .ao�eess u o�l/.�-a+v.-�-=/
� Certified copy is filed with the coonty building inspeo- gt1iLDING (` �
tian�pa1lmBnf. � �^ ADDRESS ,J w� . � � LOCALITV ��.
�7- J / �l S NEAREST
Dme,���j�°�^PPlicant Ln»ti%'AY-iL'WS a'�A�f7e�� CITY + ZIP /� CROSSST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE $IZE OF LOT NOW ON LDT � MAP BOOK PAGE PARCEL
(This section need not be Complefed if ihe permit is for one USE ZONE MAP /
hundred dollars($100)or less.) TRACT etOCK LOT NO. Np. M�t� fJ
�' TEL. �� ,� SPECIAL
I tenify ihat in the performante of ihe work"for which this OWNER t �C � " NO. CONDITIONS �
permit is issued,I shall not employ any person in any manner DISTRICT GROUP 7YPE FIRE PROCESSED BY �
so as to become subjecl to the Workers'Compensation Laws. P.DDRESS �� l� CONST. ZONE �
Dote AP(.11itplli QTY sA� Z�P ' "' STATiSTICALCLA551FICATION ( • APT. C DO. (�.,
ARCHITECT OR �J q
NOTICE TO APPLICANT: If, after moking rhis Certificote of ENGINEEe � � " "�' ` t7c� '�
Exempfion, you should become subject to ihe Workers' �- "� � ClASS NO. DWELL UNITS �
Compensation provisians of the Lo6or Cade,you musf forth- qDDRE55 SEWER MAP '�'
with comply with s�ch provisions or ihis permit shall be �
deemed revokec�. CONTRACTOR � � �_ � EL.'�6 BK PG VALIDATION �
LICENSED CONTRACTORS DECLARATION ii�
I hereby affirm that I am licensed undei provisions of Chapler 9 �ADDRE55 - � � NO. �. VALUATION
(commencing with Section 700D}of Divisio�t 3 of the Business and �i� ��l
Professions Code,and my li<ense is in 4ull force and effecf. G7Y ,Y� �2-1- CLA55 �'�fs $ � �hV � ►
'],v /�,�� Sq.FT. .OF p NO.OF CHECK
License Number��Q��_Lic.Class�= SIZE / TORIES r FAMILIES ONE
�� >� f�� � c NEW �
� �ESCRIPTION OF WORK '� � �
CoMracrorQ�Cu��..L�-✓hlYnS .Date__L�iL� � AOD � �`i SJ.Q,�{
7T T
�I am exempt der Sec. q�TEp � FINAL ('/ � � � 4
� � � DATE -f,�'E� C� �r °G.�
B.&P.C.for ihis reason % �� � �- REPaie �
Date: USE OF � -/ FINAL . - � C.{,.G C
EX�ST�N �DG. �;/ rZ `7— �EAft�� p
Signafure APPPR�NTT +2/•�.� /8 P NO. . ,p��� BI �' ` ., ,. G`1`:l��
OWNER-BUILDER DECLARATION
I heraby affirm thot I am exempt from ihe Contrador's License / �' � � (;ij�J-Y',C
Law for the following reason(Section 7031.5, Business and P.DDRE55
Professions Cade): pRE
OBUILDING
I, as owner of fhe property, or my employees with ADDRE55
wages as their sole compensation,will do the work and
the structure is not infended or offered for sale(Settion LOCALI7v _ _ r A
7044,Bvsiness and Professions Code). MOVING TEL =� � ��
� I,os owner of the property,om ezclusively coniracting NTRACTOR NO. c Q I
with licensed contractors to construct the projett(Seo qD�RE55
tion 7044,Bosiness and Professions Code). e �`;��"
CONSTRUCTION LENDING AGENCY REQUIRED yqRD HWY TOTAlSETBACK FROM EXIST. '
SET BACK PROP.LINE 'NID1H
1 here6y affirm thot there is a constru<tion lending agency for FRON7 , �e •� � _ �i'�s
the per4ormance of the work for which�his permit is issued P.L. ��
($ec.3097,Civ.C.). SIDE
- P.L. u�.l (-R EJ
Lender's Name /�
� Lender's Address P.C.Fee$ af..�,U'jJ pe�m��Fee 'a�
� I wrtify ihat I have read this opplicalion and sfate ihat the luuance Fee ��'`S Z
¢ obove informotion is mrrect.I agree to comply with.all County in�esrigotion Fee y
� ordinonces and Siote lows relating 10 6uilding construction, Total Fee �� �S
� and he�eby authorize representotives of ihis County ta eMer
� upon fhe a6 e-mentio properTy for inspection po ose� � " "' - � ' - - �
a
� � SEE REVERSE FOR EXPLANAiORY LANGUAGE _
n Signat f ppliwnt or Agent�— Date �s
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