HomeMy WebLinkAbout9997A 9998AWORKERS' COMPENSATION DECLARATION
hereby affirm that I have certificate of n, to =elf APPLICATION FOR BUILDING PERMITinsure, or a certificate of Worr kers' Compensationtion Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company n
Certified co is hereby furnished. PY Y FOR APPLICANT TO FILL IN BUILDINGADDRESS
Certified copy is filed with the county building inspec- BUILDING i
tion department. - ADDRESS
Date "' Applicant CITY
r
ZIP LOCALITY ..r"..
7CERTIFICATEOFEXEMPTIONFROMWORKERS' ' _77, SIZE OF LOT
NO. OF BLDGS.
NOW ON LOT NEARESTCROSSST
COMPENSATION INSURANCE '- ASSESSORThissectionneednotbecompletedifthepermitisforoneTRACTBLOCKLOTNO. MAP BOOK PAGE PARCELhundreddollars ($100) or less.) TEL
OWNER NO. USE ZONE MAP
I certify that in the performance of the work for which this NO .
MALpermitisissued, I shall not employ any person in any manner ADDRESS CONDITIONS asoastobecomesubjecttotheWorkers' Compensation Laws. OCINZIPU
Date Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate of
ARCHITECT OR
ENGINEER TEL. NO. DISTRICT GROUP TYPE FIRE PROCESSED BY J
Exemption, you should become subject to the Workers'
CONST,.. ZONE
I f.
ti\ "
S
Compensation provisions of the Labor Code, you must forth- /
with comply with such provisions or this permit shall be
ADDRESS
TEL APT CONDO. QSTATISTICALCLASSIFICATION
deemed revoked. r CONTRACTOR NO V OC
LICENSED CONTRACTORS DECLARATION j; LIC. CLASS NO. DWELL. UNITS
I hereby affirm that 1 am licensed under provisions of Chapter 9 ADDRESS NO.
commencing with Section 7000) of Division 3 of the Business LIC. SEWER MAP
and Professions Code, and my license is in full force and eff[' t. CIN CLASS
BK VALIDATION
SO. FTS NO. OF NO. OF CHECK
License Number - Lic. Class
I' SIZE t STORIES . FAMILIES ONE
t .
1 _ VALUATION
Contractor- Date DESCRAION OF WORK NEW
I ADD , pop1amexemptunderSec
ALTER
BAP.C. for this reason Fi
REPAIR
Date: USE OFEXISTING BLDG. j'
DEMOL L ',- ^, i I,
Signature APPLICANTPRINT) TEL. NO FINAL
OWNER -BUILDER DECLARATION DATE
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PREBUIDDI By t ".
I, as owner of the property, or my employees with
ADL
wages as their sole compensation, will do the work and i., G
the structure is not intended or offered for sale (Section LOCALITY - -- h
7044, Business and Professions Code.) MOVING - "'",•^ TEL.
I, as owner of the property, am exclusively contracting
CONTRACTOR
with licensed contractors to construct the project (Sec- ADDRESS
I s
tion 7044, Business and Professions Code.)
L,. .- (.:
CONSTRUCTION LENDING AGENCY REQUIRED
SET BACK YARD HWY TOTAL SETBACK FROM
PROP. LINE IST. WIDTH L
I hereby affirm that there is a construction lending agency for FRONT o •'.. C: f. (; L,-,, the performance of the work for which this permit is issued
Sec. 3097, Civ. C.). SIDE
Lender's Name
LDMA Ref. B
Lender's Address P.C. Fee E i ' Permit Fee
I certify that I have read this application and state that the Issuance Fee -. LOMA P/C It
above information is correct. 1 agree to comply with all County Investigation Fee
ordinances and State laws relating to building construction, Total Fee S T LDMA Perm. 8
and hereby authorize representatives of this County to enter
upon the obove-mentioned pr4k rty for, inspection purposes.
n "' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date