HomeMy WebLinkAbout1722A (10) 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
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