HomeMy WebLinkAbout1022A (9) . WORKERS'COMPENSAiION DECLARATION .. . . . ..... .. . - _ I . . ��
I�hereby afFirm that I hove a ceniiicare ot mnseni�0 5e�f :. .. . �- APPLICATIQN FOR: BUILDING PERMIT
'insore,o�a certifica�e of Workers'Compenstion Insurante,or ,
a certifled topy ihereof($et.3800,Lob.C.) . . .. . . . - COUNTY OF LOS ANGELES � � � BUILDING AND SAFETY . � .
Policy No. � Compony � BUIIpING
� Ceiiified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 � �J� i[I� Iq'� �Y�
� Lertitied copy is i�led with the munty boilding inspeo , BUILDING 7 �/,! G'�� � � . /� . ,
lion deportmenl. . . . ADORE55 -J iZ 3 J ��,�.CJ (J.0 t'-�L tOCAUTY N !L7/Q
� � � � ' � � /J NEAREST A /�
-Dola Applicont - CITY L7A� ZIP� CROSSST. i! (.�
' CERTIFICATE OF EXEMPTION FROM WORKERS" NO.OF BLDGS. ASSESSOR
�- � COMPENSATION INSURANCE � -�- SIZE OF lOT NOW ON LOT O MAP BOOK PAGE PARCEL _ �
�This section need not 6e comple�ed if Ihe permif is for one u E ZQ NE Mna � '
hundred dollars(5100)or Ie55.) � _ TRACT�� BLOCK LOT NO. � �� I NO. }
nr TEL. ` .y SPECIAL p�
� � OWNER V�1 A� / lCL:E NO�7' / I��D CONDITIONS
. 1 cer�ify that in 1he performance of the wark for which this.� u
permil is issued,I shall no�employ any person in any manner DISTRICT GROUP iYPE FIRE PROCESSED BY.
AD�RE55 j� R7'1�Fr
�so os to become subject�o ihe Workers'Compensatian Laws. �O � COnl S% ZONE , O
�'
Oa1e � � Applican� ' � ��TY�� N � Z'P STA715IICALCLASSIfICAIION . - API. CONDO: � V
NOTICE TO�APPIICANT: If, aher making this Ceitificate of - � ARCHIiECTOR J EL ,
�Ezemplion, �you shvuld become suhjed lo Ihe Warkeri ENGWEER / rJ O � CLASS NO.���WEIL.UNITS N
Compensation provisions of the Labor Code,yoo musl fonh- � qDDaf55 � �✓ �/. � SEWER MAP . �
with comply with such provisions or ihis permil sholl be TE� . � _'
deemed revoked. � • - � � fONTRACTOR � � �� � NO. � bK.� PG,� , VALIDATION
• LICENSED CONTRACTORS DECLARATION �.., tK. �
I hereby al(irm that I am licensed under pro��sions of Chapter 9 � . nD0ae55 NO. VALUATION �.�s �
(mmmenting with Seclion 7000)of Division 3 of the Business and uC. �l'MO . �� Q 2�A
Professions Code,and my license is in foll force ond effecl. GTY ClASS S W W - .
� � � SQ.FT. NO.OF NO.OF CHECK � -
licenseNumber LicClo55 � SiZE �� STORIES FAMILIES ONE . ��� �'.�,�23 �
. � � _) NEWi 5 . ��.��i8QS0
Con�roclar �ote � DESCRiPTiON OF WORK R • , 7[� Q � , . _
� I am e�empl from Ihe licensing requiremenfs os I om o � r1 AOD ��
-licensed archited or o regis�ered professionol engineer , � _ _ . . F� AtTER � �- FINAL �� � �$4 8��
, ' otling in my professionol mpaciy (SeUlon 7051, REPAiR � DATE �2�Jr�8.� .
� Business and Professions Code). U5E OF FINAL � - -
� � EXISTING BLDG. �� � � � DEMOI ❑ BY . ,
LiC.Of RCg.N0. DO1B A77lICANT y� �/ .TEL. � '
-� OWNER•BUILDERDECLARATION "� � � 'IPRWTt jYyEI��PN � ' NO.
I hereby affirm that I am exempt 6am ihe Conirocror's License � u . [. � . �
� Law(or the following reason(Section 7031.5, Business pnd ADDeE55�3 �v�r�,e.� P.�-C(7�u0 _p J,��I✓
Professions Code): � , FRESENT � �` �j�
❑ . : . _.._ BUtLDING___..__._____'_._ _�...__'__....... . ' ._ _ -. ._ � . � _ . .
I, as owner af Ihe properly, or my employees with � A�ORESS
woges as their sole compensation,wJl do th?work and ,�_A/ � .
the strvtture is nm intended or offered for sole(Secrian LOCAUTY - - ���� � �- � - - . ,
70d4,Business o�d Professions Code�. � MOVING TEt. E � � �
� I,oS owner of the property,om eadusively c0��ro[ting � CONTRACTOR NO..� � � ,
w�th licensed mntroctors ro constroct�he proleu(Sec- �
.. 't�od7044,Busine55 ond P�ofessions COda). . ADORE55 - . . .. . _ . . .
RE�UIRED TOTAL SETBACK FROM E%IST. '
CONSTRUCTION LENDING AGENCY SET BnCK vARD Hwv pROP.uNE wiDTH �
�I hereby affirm�ha�there is o construction lending ogency for • faOM � ' '
tha performonce of Ihe work for which Ihis permil is issued P.L, � �
(SeC.3097.Civ.C.�. . . . SIDE-. - . . - •
P.L.
Lender's Name . _ � � � ,
. ., . . . . . � .
lender's Addre55 � ' P.C.Fee S �• Permi�Fee
I rer�ify that I have read this application and sta�e ihat the �, �esoa�ce Fee � � .
obove information is correc�.I agree ro comply,with all County , in.esr�goi'�on Fee-��� � �� � � - - -
ordinances and$fote laws reloting�o building conshuction, '� � Toral Fee � ' � �
ond hereby outhorize represemmives of rhis County io enter . . _ . _ , . .
� upon the obove-meNioned property for inspeclion purpases. � � . �
' �- SEE REVERSE FOR EXPLANATORY LANGUAGE �
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