HomeMy WebLinkAbout0370A WpRKfRS'C'pMPFNSATION DEC�ARATIpN •' +` �
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� insureborafcertifca}teofWorkes'�Com,peosaPionenwranelt f'IPPLICATI4N FOR BUILDING PERMI� �
or a cerrNed mpy ihereoi(Sec.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. � Company �
.�
� Certified copy is hereby furn�shed. FOR APPLICANT TO FILL W Bu����Nc
ADDRE55 D
.� Certified ropy is filed wifh ihe county 6uilding inspec- eUIL�ING .� ' '�
+�� tion department. ADDRESS � " - i
Dafe � Applicant '� - � ' � CITv ;, - ZIP ' ' IOCALITY ....
� CERTIFICATE OF EXEMPTION FROM WORKERS' �� NO.OF stDGS. NEARESi �
COMPENSATION INSURANCE 5¢e OP LOi NOW ON LOi CROSS ST.
{This settion nead no�be completed if ihe permit is for one � ASSESSOR }��
'�, hundred dollars($100)or�ess.) TRACT �� '«:�••$LOCK LOT NO. /�pp qpOK PAGE PARCEL
TE� USE ZONE �P �
I certity thot in the performonce of the work for which 7his OWNER-���'C �;_ NO.� - ND. �� �
SPECIAL �
;�permif is issued,I shall not employ any pe�son in any manner qODRE55 � CONDITIONS � � �� - '"1
:�so as to become subject to�he Workers'Compensation Laws. y�
.iDate�� Appiimnt ' qTY � �: � ➢P �.:. . .. , �
ARCHITE[T OR TEI. DISTRICT GROUP TYPE FIRE ��PROCES.SfD BY
NOTICE TO APPIICANT: If, after making�this Certificme of CONST. ZOfJE ,. �
��Exemption, you.should 6ecome su6ject to the Wo�kers' � ENGINEER NO.
-;.Compensation provisions of the Labor Code,you musi forth- -, qDORE55 Q
.,,: >
�with comply with such provisions or ihis permit shall be — �"� '� "'"�-�
� .—deemed re�oked. TE� , STATISTICAL CLASSIFIUTION APT. CONDO. , c�
= CONTRACTOR , NO �-1
� - LICENSED CONTRACTORS DECLARATION ��� ci.4S5 NO. ' OWEII.UNITS E"'
'I hereby af4irm that I am licensed under provisions of Chapter 9 ADDRESS-� � ' � NO. '- ' " ��R�P
-(commencing with Section 7000)of Drvlsion 3 of ihe 8usinass and � LIC. . �.
� - Professions Code,and my license is in full force and effect. Cnv � -` C�n55 BK � VALIDATION
: ;:: .....-
•' , �t, '- + - SQ.FT. ,. NO.OF NO.OF CHECK
,:. ���-Litense Numbe �' �-'� LiC,Class SIZE ` % $TORIES r� fAMILiES x� ONE
.- , YALUATION , r-+ � �
� � �r -�DESCRIPTION OF WORK � NEW � � �� �"�
- ::.C�ontractor ,.-.� �... . _,.r Date ' . .. �' . _ ADD � s , y.:0+�m a�,1
I am exempt under Sec. '� ' `f � �
ALTER «
� B.BP.C.for this reason S '��A� �'�i`�"��
REPAIR
Date: ' USE OF OEMOL ,�'�g'���±'--'�"��g.
E%ISTING BLDG. � � !� �
Signature APPIPRINT) NO. FINA�. �"� E�w!.�t_
� OWNER-BUILDER DECLARATION � DATE
- � I hereby affirm Ihat I am exempt from the Contrador's license
�� � ���:�- Law for the following reason(Section 7031.5, Business and ADDRE55 FINAL
` Professions Code)� PRE M � BY
- .��: O _ BUILDING .
i, as owner of ihe property, or my employees with ADDRE55
wages as their sole compensation,will do the work and
. ihe structure is not intanded or offered tor sale(Section tOCnuiY ,`
7044,8usinzss and Professions Code). - MOVING 7E1. ,
- � I,as owner of the property,am excl�sively contracting CONTRACTOR NO.
with licensed coMractors to consirud fhe projecf(Sec- pDDRESS
tion 7044,Business and Professions Code).
- CONSTRl1CTION LENDWG AGENCY . S�BACK �ARD HWY TOTApROP.�LME R WIDTH �
4
�. I hereby affirm thai there is a construclion lending agency for FRON7 �� �
ihe performance of the work for which this permit is issued P.t. �
`- (Set.3097,Civ.C.). SIDE
P.L.
: Lender's Nama
-� IDMA Raf.#
m Lander's Address P.c.Fae 5 aarmn Fee ' - �
� - I certify ihat 1 hove read ihis applitation and sPata thai fhe lasuance Fee LDMA P/C fl
- above informotion is correcr.i agree ro comply with oll County �. invesfigarion Fea � � �
ordinances and Stote Iaws relating to building consiruction, Toial Fae - LDMA Perm.#
'. and hereby authorize representatives of this County to enter
upon ihe above-mentioned property far inspection�purposes �
�� � �� � . . . -. SEE REVEflSF FOR EXPIANATORY LANGl1AGE
^- . SignaWre of Applicanr or Agent �ate
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