HomeMy WebLinkAbout1238A 1571A (6)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, orfa certificate of Workers' Compensation Insura^nc�e,��{].
orac@fit{ �..pr7I( eg3sr
PPolicy o. Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date .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, after making this Certificate of
Exempton,you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
ith comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
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 °4'< 5 L- l q Lic. Class y2
yyyyc%!!II p f
Contractor %Y�i � � 1-t-6 yi+ Slc-"'F' Date
I
am exempt antler Sec.
B.&P.C. for this reason
uote:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law 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 affirmthat there is a construction lending agency for
the performance ,f the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
S
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
g ordinances and State laws relating to building construction,
d and hereby authorize representatives of this County to enter
upon the Above-mentioned propel for ;nspection purposes. /
Signature of Applicant or Agent Date
i
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL 1N
ADDRESS
BUILDING I
ADDRESS=11 - litl L,/i :�. FfTf-: i,/C #.:2. 1� L.7f Vci
LOCALITY �a
CITY C.�a
NEAREST s
CROSSST. Sk
LK
Q
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT NOW ON LOT
MAP BOOK
PAGE PARCEL
USE ZONE
MAP
TRACT BLOCK LOT NO.
NO.
a 711i
tr�n
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SPECIAL
OWNER , i i C..C'I r -r a° f p-.'f✓`I NO. -- ( - `
CONDITIONS
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ADDRESS - '"� '� l�%L' CI N Y1 6 r, Dr.
DISTRICT GROUP TYPE
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FIRE PROCESSED BY
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STATISTICAL CLAS`�I]FICATION
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CLASS NO. `^� DWELL. UNITS_
1
ADDRESS,` 1''iAl.'s D1- 3L—A
SEWER MAP
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CONTRACTOR M0,inAlKle- NO
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VALIDATION
uC.
ADDRESS f'1 -i i "> e_I-. f 'C. NO.
VALUATION
_ LIC.
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CITY - f CLASS
$
SO. FT NO. OF NO. OF CHECK
,
SIZE STORIES FAMILIES ONE
n
2 1 C. 3.8 A
DESCRIPTION OF WORK .. NEW ❑
$
# a e •. 0 2.3
ADD
C.Lns7 r ALTER ❑
;,e
FINAL / % /
I
eel . y. 7 a ' - REPAIR ❑
DATE /� %
s ® 0 6 4.8 1 O
USE OF A,/ {
EXISTING BLDG. L:...Lt.' rm Y c"t i e- f e6e. ❑
FINAL
01.25-84
APPLICANT �. .. > TEL / LLEMOL
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SEE REVERSE FOR EXPLANATORY LANGUAGE
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No.
0 N" R 3U FF K TION'
herF by c rri fm: figm the Cor'ractor's
F.aIursved _ j �cE L fc 41b f.11—mg n (S., 7031.5)
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-
a- "'t - iie-t t t d or aff—d`.r sale(Sec /C4:
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Wat Ca i
•
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