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HomeMy WebLinkAbout1722A WORKERS'COMPENSATION DECLARATION � � � ;�s��ebo�°a`�e,;i�a',eofwoke=-'�omPe�sa;o���5��a��a` APPLICATION FOR BUILDING PERMIT or a certified capy�hereof(Sec.3800;Lab.C.) COUNTY OF l05 ANGELES BUILDING AND SAFETY Policy No. Company BUIIDING � Certified copy is hereby furnishad. FOR APPLICANT TO FILL IN ADDRESS �'3 J �� � � Cer�ified copy is filed wilh the tounty building inspec- eUUDING .� lion deportment. . ADDR I LOCAUTY (—�I_ NEAREST Date Applicont � CITV �('ZI7� 1 1�o� CROSSST. CERTIfICATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. ASSESSOR COMPENSA7ION INSURANCE . SIZE OF l0T NOW ON lOT MAP BOOK PAGE PARCFI �This section need not be completed if the permit is for one u NE AMP hundred dollars(5�00)or leis:) iRAR 2� �- BIOCK LOT NO. �, NO. �'�'0"��� � 1EL. �U U J 57ECIAL I certify thoi in�he parformance of Ihe work for which this OWNER Ay � [7c.rNr�No.£iGl- i3s CONDITIONS a permit is issued,I sholl not employ any person in any manner r� �! OISTRICT GROUP TYPE FIRE PROCESSED BY � so as to b me subjecf to Ihe Workeri Compensalion Laws. ADDRE55 3J ��.y/�'jlc3�� /� CONST. Z � �� 6 �Date �a • CITY / O Z�P �7 STATISTICAL CLASSIfI TION APT. ONDO. O lOTICE TO A tICANi: If, after making} is Cerlificate of ARCHITECTOR TEI. Exemption, yo� shouid become subject to fhe Workers' ENG�NeER NO. QA55 NO. �WFlI.UNITS a Compensation provisions of the labor Coda,you must forth- qDoae55 sewek nw.a �^ with comply with such provisions or this permif shail 6e z deemed ravoked. � � - -TE�' VALIDATION CONTRAC70R BK• �� � � LICENSED CONTRACTORS DECL4RATION � - LIC. 1 herehy affirm that I am licensed under provisions of Chopter 9 ADDRESS NO. VAtUAT10N (commencing wiih Section 7000)of Division 3 of fhe Business and �i�. �•� . - Professions Code,and my license is in full forte ond effect. CiTr CtnSS 5 � � - SQ.FT. NO.OF NO.OF CHECK � License Num6er Lic.Closs � SIZE 00 STO FAMiLIES ONE � Conlmctor pote DESCRiPTiON OF WORK NEW � s • �I am exempt under Sec. ADD � AITER ❑ FINALp 2�� DATE_�y-� 6.8P.C.for this reason USE OF � REPAIR ��� 7 2.2 A FINA4 • • • • �� Dale: E%ISTING BLDG. D�� � BY \�J / � � • •4�j,Q Q - Signafure - APPLICANT TEL. , OWNER-BUILDER DECLARATION - � � �aiNt NO. • • •4 a 0 0� I hereby afSirm�hat 1 am exempt from the Contractor i License qDOR[55 ► � 0�,2 9-8 5 Law for the following reason(Section 7031.5,Business and Professions Code): . , BUILDING �� I, as Owner of Iha proparty, or my employees wilh ADDRESS �� � wages as their sole compensation,will do the work and ip�qttTv . the strucrore is no�in�ended or offered for wle(Section . � 7044,Business and Professions Code). � MOVING iE�. . -- � I,as owner of iha propeny,am exclusively tonlracting CONiRnCiOR NO. wilh licensed contractors to construct the project(Seo- qDORe55 � - tion 7044,Business and Professions Code).. � , � � � REOUIREO TOTAL SETBACK FROM EXIST. � � CONSTRUCTIOJJ LENDING AGENCY . SE7 BACK YARD HWY pROP.LIN WIDiH , � I hereby alfirm Iha1 there is a consliuclion lending agency(or . � FRONT � ��� � �he performance of ihe work for which this permil is issued P.i. �Sec.3097,Civ.C.). ". SIDE i. . . . .P.L . Lende�'s�Name � '� P.C.Fee S Permi�Fee �.S� lender's Addrass � (-�) � � I cerlifylhat I have'read this application ond stale that the � issua�ce Fee ��." `� � � above iniormation is correct.I�agree b comply with all County Inves��goi�on Fea � - ordinances ond 51ate lows relaiing to building construdion, - Torol Fee 3•�� Y1 nnd hereby autharize representalives of this County to entar � upon above•mantioned p perty for inspecfion purpo s. � �� � � � - � � �/yq ,/� . SEE REVERSE FOR E%►LANA70RY IANGUAGE ' Sig tura of Appliconl or AgeM - pate . . ..�t P'" .t. 1: ` , � 1 � L —4.'4 ' . _' ' _ ', .� , ^ + , ' N � V.4 :."" Q Q) C � n C� � . `_ �` - . . . �� . 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