HomeMy WebLinkAbout1498A (8)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. - Company
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Data 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 per 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 Aplicant
NOTICE TO APPLICANT: If,.after making this-Certificate'of
Exemption, you should become subject to the Workers`
Compensation provisions of the Labor. Code; you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
1 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 tit. Class
Contractor Date
I am exempt under Sec.
B.BP.C_ for this reason
Date:
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
rofessions Code):
I, as owner of the property, or my employees with
111"`-"`��� wages as theirsola compansatlon, 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 affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
ISec. 3097, Civ. C.). -
Lender's Name
8
Lender's Address
I certify that I have read this application and state that the
above Information is correct. 1 agree to comply with all County
ordinances and State laws relating to building construction,
>y an hereby outhorize representatives of this County to enter
Zthe above- ent'
o oed property for inspection purposes.
sic �v ,SEB 13 Lel/
Signature of Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADD ..s 5 FL) NTI-6r
le
BUILDING 51
ADDRESS
/ A HT1_ O /, [! RD
/. 7L/y L�iC
I��
LOCALITY Iii iT1Q D
L —
CITY
ZIPq1 26
N
CROSSEAREST 5T. 1 G hl 1- N N Q V LI - 1 f - /ft rk-1)Nr
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT O X
/<0NOW ON LOT /
MAP BOOK PAGE
PARCEL
USE ZONE
MAP
TRACT
BLOCK LOT NO.
NOTEL*.
OWNER U ID
` �+ /
E2 NO. 7 -9
��'/u
SPECIAL
CONDITIONS '
- I S
�-•�—
_)_ 1/ r J_6C - D
DISTRICT GROUP TYPE FIRE
CONST. ZONE
PROCESSED BY
ADDRESS
/
/D
CITY M ONID. _1 ZIP 9/765—
ARCHITECT OR
: .
TEL
STATISTICAL CLASSIFICATION -
APT. CONDO.
ENGINEER
NO. .
CLASS NO. '-"74 DWELL. UNITS
ADDRESS.
- -
SEWER MAP -
CONTRACTOR
TEL
NO.
.- BK. PG,
VALIDATION
LIC.
ADDRESS
NO.
VALUATION
S � Jr� �
� 1 4 9 8 A
CITY
CLASS
SO. FT. NO.
OF NO. OF CHECK
,
• • • • '� 3
SIZE STORIES FAMILIES ONE
d
i
s
-51L1 9
DESCRIPTION OF WORK
5 1 NEW ❑
'
LL
`J -/yr 0 ADD ❑
•••5419
ALTER ❑
FINAL
3-84
1L/'T`
LGC/G LDP G REPAIR ❑
DATE
.021
USE OF
EXISTING BLDG,
OUSE DEMOL ❑
- FINAL
APPLICANT r1.,. ..
_ �. ,._ .. ..TEL ..-. _ .. , ..
By
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