HomeMy WebLinkAbout1784AWORKERS' 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
Cerified copy is hereby furnished.
❑Certified copy is filed with the county building inspec-
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 to become subject to the Workers' Compensation laws.
Date Applicant
NOTICE TO APPLICANT: If, offer 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 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-
1 1 am exempt under Se
BAP.C. for this reason
Date
Date:
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 properly, or my employees with
ages 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.).
Lender's Name
Lender's Address _
I certify that I have read this application and stale that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes.
Signature of Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADDRE BURDNG
1:91 �!
BUILDING
ADDRESS Q�PI /fytjiYLi
CIT
ZIP
LOCALITY &
NO. OF BLDGS.
NEAREST
SIZE OF LOT
NOW ON LOT
CROSS ST.
TRACT 5429,Qff IBLOCK
LOT NO.
ASSESSOR
MAP BOOK
I PAGE
I PARCEL
OWNER
� NO
NO.
USE ZONE
K ^ r
OSPE? v
CIAL
ADDRESS
/I�'e'ap,
(rU O
CONDITIONS
CITY
ZIP
ARCHITECT O
TEL.
GROUP TYPE FIRE PROCESSED BY
ENGINEER
NO.
�QISTRICT
jxj i 1 ,// CONS j.�-1� ZONE
V l�� .J✓
STA ISTICAL CLASSIFICATION APT. CONDO.
ADDRESS
TEL.
CONTRACTO
NO.
•Q"�
11 '1
CLASS NO. DWELL. UNITS
LIC.
pJ�yr.,
ADDRESS
NO.
SEWER MAP
' LIC.
CITY
y CLASS
BK. PGVALIDATION
SO. TT. NO.OF NO. OF
CHECK
SIZE STORIES
FAMILIES
ONE
VALUATION
DESCRIPTION OF WORK
NEW ❑
ADD
$ 1 / 8 4 A
C J
r
ALTER
REPAIR
E L❑
e o e �, 0 C
FINAI
GATE i) Lr. 1 % `-' %
USE OF
EXISTING BLDG.
APPLICANTPR NT NO.
ADDRESS
FINAL
By
PREbENT
BUILDING
ADDRESS
LO
MOVINGTEL.
CONTRACTOR
NO,
o
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK
PROP. LINE
WIDTH
FRONT
P,L.
SIDE
P.L,
LDMA Ref. #
`,....,'LZ
P.C. Fee S .sue j r C
Permit Fee
LDN P/C # ,
Issuance Fee
Investigation Fee
Total Fee
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE ►Liss+—• C"4--l