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HomeMy WebLinkAbout1638A (9)WORKERS' COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self ,,,sure; dr a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C. Policy No. Company Certified 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 "'5. 9 4' Applicant 1{ -�•< 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 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 Dote 1 am exempt under Sec. B.BP.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, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Cade). 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, CY. 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, and hereby authorize representatives of this County to enter upon the above -mentioned property for inspection purposes. APPLICATION FOR .'BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN ADDRESS BUILDING ZZ ADDRESS .,Z •`?{✓.7� /7r I'i/U Y'f,'. LOCALITY �7 !� '.t J CITY "tear .� S?J R ZIP f �_j u i* / NEAREST CROSS ST_ NO. OF BLDGS. SIZE OF LOT ,4�� ' NOW ON LOT % ASSESSOR MAP BOOK PAGE PARCEL _ �p TRACT ., 'F BLOCK LOT NO. 4-3 USEZONE-- MAP NO. ,/ { OWNER C r�s+"Md riO. SPECIAL( CONDITIONS DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS • S 0 --J' r'g-J' 1,; 0 CONST ZONE . -Pi, Y iTT ;/� PL•) CITY--�'!i is:✓d P3 ,1 i' zip p-7fs ..�> ARCHITECT OR TEL STATISTICAL LASSIFICATI STICAL C APT. CONDO. ENGINEER NO. CLASS NO. DWELL. UNITS ADDRESS SEWER MAP TEL. CONTRACTOR `r` I ) , o r NO BK. PG; VALIDATION LIC. ADDRESS NO. VALUATION - $ C K CITY CLASS SQ. PT. � i NO. OF NO. OF CHECK X• - ` 1 �' 8 A SIZE / STORIES P FAMILIES ONE DESCRIPTION OF WORK 1 /"3 Y" i C e NEW Ely� " ADD •t fi", d i`''1) t, O I o e 4 JV.O 4-:' !`2..e ..i. ALTER FINAL DATE .. a e 1, -�,+JC, �. REPAIR � USE OF ? DEMOL FINALIl F` 4, .0 EXISTING BLDG. r`0 w �z By APPLICANT I TEL + tf PRINT r rrrA r-. re NO. ADDRESS •'.k 9 7Pi nfn!'t+t.:, '�i� .JiP77F?i:yg i qi-' PR NT BUILDING ADDRESS LOCALITY MOVING TEL, CONTRACTOR NO. ADDRESS - REQUIRED TOTAL SETBACK FROM EXIST. "-SET BACK YARD HWY PROP. LINE WIDTH FRONT P.L. SIDE P.C. Fee $ Permit Fee one Issu e Fee Investigation Fee Total Fee ra L� Cltal •-yj - - ! SEE REVERSE FOR "EXPLANATORY LANGUAGE _ Signature of Applicant or Ageii�— Date ®s INSPECTOR'S K0795 ! To: I Rel.urned _ '' das�a3red Date R®ceivsd or Appmved Water } 14—ith Uepa haion, Ffr. D.p mart G odin Padest,i— Protection I (Ferce) (Ccncpy) I - ! S^.aa nspect'on (Cone.) (Rhasonry) (Welding). - -- Lot vrainacu,.> ---- -- 1I Parking I }AFF"o, :3 f� Ga:e j I:tnpmcto". signet-o — 1 �.-- ( (S.tiac� to 'a FoUnd6 on_ ! 0. 1\ $Ian Enwgy 1r15'.'IG}: on ,niaricr I TfI Lath—Eu4c-rior � `( — _ - - House Plumber-- j �Correc9 & . - En`er cry Frcnt 1 Ih_ - - C9it NT,R-€3W.LDFs i DGCI.!` RA.I'iO\ - I her b. ,affirm that I.,.o om i trom Ir.e, Can ro Le n e L.,ii for the, folloe ;ng reo on (Sec 7031'5) Code.. G,•y ei J or eou^ ty t. bseh • � t <..: u t dra ✓s, desn�luh; OP aS 5, 5 ) [C Sr e7 O es ..4It n-, a!so -q.i-s eb apple—, f— s Persrst Eo %s c. a'signed s te—m 3 s l c rs 4 t t '-e,sra rrsr.s— of tl Cnn- r t' rsn 7 (Cl 5 es ,:ror r^ rc :g .1 Se - t o t e r U) o3tu nn 3 f tk- B—i— hj ss e + e" frorrr a d thlw sfr .b© r. k ...zc pd sn !n sdetsnn of S eds r 7031.5 b !, a of 0 6i an - t, ere cusrars I Sty©!YJ J: I. a o e c ;he p Qpe ty or.r y enoio ees with wag- - their sn cc c 'on Mill do he work and The sieuctu, s:mot-irazided'x o ier d for s I (Se 7 i4 La", a— .;o apply in an >..,vter of h .rysrry wb. vud&s nr r p t-st n v � t' s veFr eor bsrs lfo aF r de u cl i.- ftqr sal Id ssxae;d onr vill d 1 c o ne;_rcr ry, ere c's iyco.Pmc- t -a coniracic s to cans r the o nl -ct (Sec 7 t.' ns d rof s c- 7fj C mtructar's — n , ,p—p—r v eeb,, bu iiki;, r. ... ti4e _vd7.rr. OS...f .L,.-h c",,x"ra, for s.,h p, rs a. i f— - s) lj- E _ ° to the L...1 Iarnec ptn=.cer Sec_ ,6.&P. C. forthis Date _ Owner.. -