HomeMy WebLinkAbout1046A 1152A (5)es
15
WORKERS' COMPENSATION DECLARATION
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1 hereby affirm that I Rove r certificate of 0anlem to self
insure, oro certificate a Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. G.)
gpp��CAT10N FOR B1 1
- V LD1 NG PERMIT.'-
Polity�
Company
COUNTY OF LOS ANGELES
iBUILDING
AND
PNo
Certified copy is hereby furnished.
Certified copy is filed with the county building Insect•
I ' / -FOR APPLICANT TO FILL IN
,SAFETY
BUILDING '
!
tiorrdeparlmont.
ADDRESS l /i�'%�:1I,/!j
--. ^�'•'r r _./
Dale Applicant
,L•
CRY//ice
LOCALITY
"
- ZIP
NEAREST /
CR0555 i
CERTIFICATE OF EXEMPTION FROM WORKERS' -
SIZE OF LOT NO- OF BEpGS. +7
-•
COMPENSATION INSURANCE
_ NOW ON LOT /
/
ASSESSOR
(This section need not be completed if thlerpermit is for one
hundred dollars (SIOO) or less.)
I TRACT BLOCK'
MAP BOOT;
USE ZONE
PAGE
MAP•
" PARCEL
/
L certify that In the performance of tfie'work for which this
LOT NO.
OWNER >f�:f f'' - � : �..
hfs""/ ♦ ;, ^.•,cr �,r; .��..:'
L' .�
NO --
SPECIAL
permit Is issued, L shatl not employ any pe son in any manner
so as to become su ject to the War erompensation Lows.
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i ADDRESS
F -
CONDITIONS -
DISTRICT ,GROUP TYPE FIRE
CONST. ZONE
ZONE
-
PROCESSED BY
-
Date ! Applita. /
I CITY
ZIP
ZIP
�n 7�
,Y
NOTICE TO AP LICANT: If, df -OF making this Certificate of
E emptlan, you should become subject to the Workers'
ARCHITEC7r0R
ENGINEER!'.!. /T /t ;�j�; ! I TEL
-%'-fir%, NO.
.
STATISTICAL CLASSIFICATION
y,f' -APT•
_
-1
'"CONDO.'^
Com ensation revisions of the Labor Code, ou must forth-
P P Y
I ADDRESS r .-
CLASS NO. -
DWELL UNITS
with comply with such provisions or this permit shall be
-f,) �.. _
- ,
SEWER MAP
• :• deemed revoked. -
r: -r, r•
�� CONTRACTOR'S �"tl / !_ TElO
•N:r % r "% % "
.. _
,
LICENSED CONTRACTORS DECLARATION
I hereby affirm thct i am lican;od under provisions of Chaplet 9
ADDRESS /� ' j /!/x - - UC..+ i
' & •
BK. FG, -
.
VALIDATION
(commencing with Set-Gon 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
NO, i-,^.
CITY LIC, .•
-
VALUATION
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SIZE -' •• NO. �-
^• / COE
-
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License NumboP Lle. Close
.
,: r STORIES FAMILIES
,
/_• �• s• �. L. i.
;:.r r /_ / .: -: - i
ConlraUor " bola
DESCRIPTION OF NEW
WORK I/. /i.;'i.,!='ir:.
$
...
am exempt under Seo.
,r ADD ❑
< ..r .. r., f • l;Y/ 9i: ; .r:.a r.l Ji
e
B.&P.C. for this reason
i'i'
ALTER ❑
FINAL
+e •r
D ate:
USE OF 11 !! REPAIR ❑
EXIST114G BLDG._t!f l '/f-!. 4 r r.r
DATE .
.
•V DEMOI ❑
,;575
FINAL
-
Signature
OWNER -BUILDER DECLARATION
U
PRINT%'({�.°ill/- TFL•/ -:!r
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By
hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
+
ADDRESS /�.�� �:.y1 �. /ryrrr•, �` �jJ.,�,Z
S - -
-'
Professions Code):
P
1, as owner of the properly, or my employees with
ADORM
wages as their sole compensation, will do the work and
-
the structure is not intended or offered for sale (Section
7044,
LOCALITY
-
S,
Business and Professions Code).
1, as owner of the property, am exclusively contractingCONTRACTOR
licensed
MOVING - -
TEL.
- .."c'
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..
with contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
ADDRESS
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o construction lending agency for
REgUIRE.
SET gaCK YARD HWYTOTAL SETBACK FROM EXIST.
PROP. LIN WIbTH
FRONT
-
e e F+ ( !,
the performance of the work for which this Permit is issued
-
P. L.
- -
,
s•I E
JSec. 3097, Civ, C.).
SIDE
I ,t
Lender's Name
P.E.
-
Lender's Address_
Permit Fee :'/
•
-
e
1 cer ,fy.lhat I hc�4e read this application and state that the
_
Issuance
abo� informatiofi is correct. I agree to comply with all Coumy
ordi�tances ond/State laws relating to building construction,
and hereby
Fee .' e'
Investigation Fee -
-,
d
ouf{horixe representatives of this County to enter
��LLpaD.ihe aboh-nient- ned property for inspection purposes.
Total Fee
SEE REVERSE
7.
Signature of Appl¢mt or Agent
FOR EXPLANATORY LANGUAGE
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15
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