HomeMy WebLinkAbout1208A 1209A WORKERS'COMPENSATION DECLRRATION ""'�
I hereby affirm thof I have a[erfifimfe of Consent to self APPLICATION FOR BUILDING PERMIT C�
insure,or o certifica�e of Workers'Compensation Insurance,
or a certified coPy rhereof(Sac.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAPETY
P❑olicy No.� Company BUILDING , �
Cer^�ified topy is hereby furnishad. POR APPLICANT TO FILL IN ADDRESS
� Certlfied copy is flled with the county bullding Inspac- BWLDING .' - '
tion departmenL AD�RESS '
Dafe Applican� UTY � " � ZIF ` LOCALITV
CERTIFICATE OF E%EMPiION FROM WORKER$' � NO.Of BLDGS.� NEAREST �
COMPENSATION INSURANCE SiZE OF LOT NOW ON LOT CRO55 5T:
(This seaion nead not 6e completed if the permif is Por one ASSESSOR �„
hundred dollors($100)or less.) TRACT BLOCK LOT NO. MAP BOOK VAGE PARCEL �_
TEI,
USE ZONE �
i cenify Ihat in the performonce of the work for whlch fhis OWNER . NO. � - - (,
permit is issued,I sholl not employ ony person in any manner � , SPECIAL LL!
so as�o bemme subiect to the Workers'CompBnSafiOn LaWs. .4DDRE55 CONDIiION$ -^�
J�� :��- � '" . . . �
�bate � ' Applicant � .' CiTY ziP � �
ARCHITECi OR TEL a=
NOTICE TO APPLICANT: If, after making�this Cer�ificafe of DISTRIC7 GROUP ryPE FIRE PROCESSEDBY �s^
Exemp�ion, you should 6ecome subje[1 fo 1he Workers' ENGINEER �� CONSi: ZONE �q?
Compensation provisions of�he labor Code,you must forth- � � ' � . � � .. C3_
ADDRE55 . ����`� �;
with �omply w'th such provisions or ihis permii shall be TEL STATISTICAL CLASSIFICATION APT. 1COND0. �
deemed rBvaked. CONTRAGTOR � NO. - !sJ
LICENSED CONTRACTORS DECIARATION ���. . . CLA55 NO. " DWEIL.UNITS M.
I hereby affirm ihot I om licensed under provisions of Chapter 9 ADDRE55 � NO. �
(commencing with Sec�ion 70pp)of Division 3 of�he Bosineu and .;��� - SewEe Ma,F
Professions Code,and my Ikense is in full force and effed. CITY � � �CLa55 BK � VALIDATION
. � ) , Sq.FT. ': NO.OF NO.OF CHECK
License Num6er � Lic.Class_r_ SIZE �'��' :�-' STORIES FAMIUES ONE
_.. . ; �+ ,. ❑ VALU!}7�ON
� DESCRIPTION OF WORK NEW
Confractar Date -�..�. f . ADD � s / � . .� , �: 4 �
❑I am exempt�nder Sec. � A�iER � �..�,�.,�, _ n.
B.BP.C.fof 1}lis reason .. REPAIR � � � . , .,, �..A,..
USE QF �!'��.C
Dote: EXIS7ING BLDG. DEMOI ❑ : ' ' ""'��'�'�'�
Signature APPLICANT TEL FINAL '�.°;'°;�'`�.'..�'4.::'�.
OWNER-BUILDER DECLARAiION PRWT NO. DATE R y.,:.
I hereby affirm that I om exempt from the Contractor's License ��...�.,,., .,,�C.
Law for the following reoson(Section 7037.5, Business and ADDRESS p�Np�
Professions Code): E i � By
QBUILDING
I, as owner of the prope�ty, or my employees wifh ADDRESS
wages as iheir sole compensation,will do the work and ,
�� �"--•-ucturz is��o'intendeo or oriered for sale(Section iocauiv F ,� �.,,'t",.F
7D44,Business and Proiessions Code). MOVING TEL ��� �`M� ..
� I,as owner of the properfy,am exclusively coMracting CONTRAQOR NO. Y, ��a���,��,Q.,i�.
wiih licensed coniractors fo consiruct the prpjetl(Set- qDDRE55
tion 7044,Business and Professions Code). t :s,,,� t �s�:
REpUIRED TOTAL SETBA F
CONSTRUCiION IENDING AGENCY SET BACK YARD HWY pROP.LINE WIDTH
I hereby offirm thot�here is a consiruction lending agency for FRONT °��;a'�^;.':;':..1.�:�(-�
the performance of the work for which this permit is issued P.L. � � � �
(Sec.3097,Civ.C.). SIDE ;;T % �'��
. .,......-,bii;:::
P.L.
Lender's Nome
�DMA Ref.M
Lender's Address P.C.fee 5 � �' Permit Pee ' � , � , .
I<erti4y ihot I have read this applicption and slate fhat fhe I65upOce Pee �� ' L�MA P/C k
above informplion is correcf.I agree to mmply wifh all Counry Investigarion Fee
ordinances and State laws relating 10 building conslruUion, Total Fee LDMA Perm,d
and hereby aothorire representatives of this County to enfer
upon�he obove-mentioned properry for inspection purposes.
� � SEE REVERSE FOR EXPIANATORY UNGUAGE
-' Signature of Appliconr or Agen� Dote