HomeMy WebLinkAbout0786A (6) WORKERS'COMPENSATION DECLARATION �
I hereby affirm thot I have a certi4imie of consent to self APPLICATiON F4� BUILDING PERMIT �
insure,or a certificate of Warkers'Compensalion Insurance,
or a certified copy thereo4(Sec 3800,Lob.C.) COUNTY OP LOS ANGELES BUILDING AND SAFETY
Po6cy No. Compony :
❑ � BUILDING .
Cerrfied copy is hereby fornished. FOR APPLICANT TO FILL IN ADDRESS �.''i : ',�-'y ,, ���;�
� Certified copy is filed with Ihe county buildinq inspeo- BUi�DING �/ j f_.
tion departmenf. ADDRE55 -ai�' - .'.'Y f,;��! �c t�..:�,
Dote Applicant CI7V__ ,.f � .'. ZIP � � LOCALITY �~.'��
CERTIRCATE OP EXEMPTION FROM WORKERS' / � NO.OF BLDGS. NEARE57 �`
� COMPENSATION WSURANCE SIZE OF lOT NOW ON LO7 CROSS ST.
(This secfion need nof be completed if the permi�is§or one .!" ASSESSOR ��
hundreif�dollars(5100)or less.) TRACT BLOCK LOT NO. z„ /�AP BOOK PAGE PARCEL n,
I certify thot in the performance of the ivork for which this OwNER j .'/` ��� . ; NO, '�� � � USE ZONE MAF �
� ND.
permit is issued,I shali not employ any person in any manner j ^>,.i �/,,/ `j� SPECIAL Li3
so as to become su6ject eo fFe Workers':Cortipensafion Laws. /+DDRE55 '. CONDITIONS �
Date Applicant "���' . �,' �... CI7v ! . �, „�:'i: ',.,,J ZiP `,//j�/: ' }
NOTICE TO APPLICANT: If, ofter making�ihis Cerfificaie of ARCHITECT OR TEI. DISTRICT GROUP TVPE FIRE PROCESSED BY ¢
Exemplion, you should become subiecl to 1he Workers' ENGINEER NO. CONST. ,. ZONE y�
Compensation provisions of rhe Labor Code,you must forth- qD�RE55 Kf' `�1� ' � �
ifh comply with such provisions or fhis permil shall be TEL STATISTICAL CLASSIFICATION `� APT. CONDO. �
deemed revoked. COMRACTOR : NO. 1:.1
.�
LICENSED CONTRACTORS DECLARATION ���_ C:A55 NO. '�4 DWEt�.UNIiS I-
� I hereby affirm fhol I om licensed under provisions of Chap�er 9 ADDRE55 NO. SEWER MAP
(commencing with Section 7000)of Divlsion 3 of the Business and �i�.
Professions Code,and my�icense is in£ull force and effed. CITY CLA55 BK � VALIDATION
SQ.FT. NO OF NO.OF CHECK
License Number Lic.Closs SIZE STORIES :;:?�+. FAMILIES ONE
VALUATION
DESCRIPTION OF WORK . �".'��"'4�� ��: NEW � �,,,����;"
C❑ontracfor Date - .^ ;'f .. •�.� ADD Q s . ,
I om ezempt under Sec. �� '4�''�t l? qLTER � "'*��'•
8.8P.C.far this reason REPAIR � S ' " '� ���M�tl�
Dafe: USE OF DEMOI ❑
EXISTING BI�G.
Signarure APPIICANT� i . J . 7EL.. .. FINAL
OWNER��BWLDERDECLARATION PRINTI.��•?�C>.:• f1 /'!,• I a..i n10.'�`'J'-;'/,y` � DATE
I hereby affirm thot I om exempt from the Coniractar's license ' �
Low for the following reason(Section 7031.5, Business ond ADDRESS ���=�af._'� � %�f � J �" :�> PINAL
Professions Code): PRE ENT BY
❑ BUIIDING .
I, as owner of ihe property, or my employees wiih ADDRESS
wages as their sole compensat�on,will do the work and ��� ' :�_�,�;`'�;�.v v_
the strucWre is not infended or offered for sale(Section �OCALITV -. . ,
7044,Business and Professions Code). MOVMG TEL ' ..�: � �.-� :�a;,a�e ,a e r
. `_.- . .
CONTRACTOR NO. ._���+-'`"' ,, '
O I,cs owner of Ihe property,am exdusively conirocting . ..,., ; , � ,-
with licensed contractors ro construct ihe project(Sec- .-- �'�°�°�J=��
tion 7044,Business ond Professions Code). ADDRE55 .,.=� t�r.� . _. . �, �
RE�IJIRED TOTAL SET6AIX F . ,,.r" '..._.... ,x g�a C..�.:s L:,
CONSTRUCTION LENDING AGENCY SET BACK YARD HWV pROP.LINE WiDTH '�" '� M.-"'�,,.
I hereby affirm that there is p construclion lending ogency for FRON7 .� �j,,,.;'?i^""� �t< '��k+-�,�(,
the performance of ihe work for which ihis permit is issued P.L. � � ' �
(Sec.3097,Civ.C.). SiDE
P.L.
Lender's Name
���:�'.. LOMA Re4.# .
�° P.C.Fee$ Permil Fee - '
� Lender's Address
� I certify ihat I have read this applimtion and state ihat the lasuance Fee �'� LDMA P/C.k
_ above informalion is correct.1 agree to mmply with ail Counry lnvesrigation Fee ti�-
ordinances and Sfate laws relating to 6uilding construction, To�al Fae LDMA Perm.N
and hereby a�thorize representatives of this County to enter
upon the above-menlioned property for inspection purposes. -- ' ` -�
/ 1
^ � :Y,!i 'i i�- '�' SEE REVERSE FOR EXPIANATORY LANGUAGE
Signature of�Applimnt or Agent ' Dote
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