HomeMy WebLinkAbout1405A 1887A (11)WORKERS' 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. 3Boo,, Lab."C.) /
Policy NoJ 213 Company5A/f
❑ Certified copy is hereby furnished. z
❑Certified copy is filed with the county building inspec-
tion department.
F n
Dote �F4 CL/ 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, aftermakingthis Certificate of
entpiiun, 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 Cr r° �J )) Lic Class
Contractor,556,,,i 7e'j h61_1111 J/ Dafe
❑ I am exempt under Sec.
B.BP.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Low 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 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 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
m upon thea .` o e-��lentioned property for inspection purposes.
�
Signature off%Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
ARCHITECT OR '.
FOR APPLICANT TO FILL IN
ADDRESS
S i /l`W.m(1 , l J
BUILDING
ADDRESS-)
' '' r I
1 fC (%v;/lC1 )'T µct.
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LOCALITY U 14r"](�✓,'(Yl
CITY
rC{kt' - Grp ZIP
NEAREST
CROSS ST.
G"`' .✓�
SEWER MAP
NO. OF BLDGS.
ASSESSOR
: � y jz .
SIZE OF LOT
NOW ON LOT
MAP BOOK
PAGE PARCEL
ADDRESS f'&
USE ZONE
MAP
TRACT
BLOCK LOT NO.
DL.
cuss
NO.
SO. FT. NO. OF NO. OF
TEL
CHECK
SPECIAL
OWNER.
F NO.
ONE
NEW
CONDITIONS
DESCRIPTION OF WORK Cgriyln,�I. //{ri'f/ /
// // 1
ISO,-
DISTRICT
GROUP TYPE
FIRE
PROCESSED BY
ADDRESS
w7LY J J,SIt'(rd
FINAL r
CONST.
ZONE
REPAIR ❑
1(O
CITY IJ)k-a1 L4.. �.{. PJ -e� ZIP
ARCHITECT OR '.
TEL
W
EINQ
-
FRONT
R L.
CLASS NO. re E
ADDRESS - - -
_. Fee $ .5� �
SEWER MAP
CONTRACTORq,14 Lo, r E' Albdo,
TEL
NO. J�
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ADDRESS f'&
NO.
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DL.
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$
SCITY
SO. FT. NO. OF NO. OF
CHECK
SIZE STORIES FAMILIES
ONE
NEW
$
DESCRIPTION OF WORK Cgriyln,�I. //{ri'f/ /
ADD El
ALTER 0
FINAL r
REPAIR ❑
DATE d E
USE OF
DEMOL ❑
FINAL '
EXISTING BLDG.
RY
APPLICANT �} q�
TEL.
PRINT
NO.
ADDRESS
DVING
)NTRACTOR
TEL.
NO.
)DRESS
1EQ IRED
iET BACK YARD H
TOTAL SETBACK FROM EXIST.
PROP. LINE WIDTH
FRONT
R L.
SIDE
P.L.
_. Fee $ .5� �
Permit Fee raZ9, ""t/
Issue ce Fee / 0. z; O
n
,estigation Fee
Total Fee .'3��'� :� a
SEE REVERSE FOR EXPLANATORY LANGUAGE
10.
VALIDATION
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