HomeMy WebLinkAbout1079A 1212A WORKERS'COMPENSATION DECLARATION - �
��=��e6o�a`�er,f�o',eo°wokersrrCom�peosationensurane" APPLICATION FOR BUILDING PERMIT
or a<errfied<opy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
��. � Poliry No. Company
Ce�tified copy rs he�eby fumished. FOR APPLICANT TO FILL IN eu��oiNG ,. ��.; -,
� ��� � ADDRE55: . �. .� ..�. __ � . ._ .
.`.� Certified copy is filed with ihe munty buildi.ng inspec- gUILDING '� , . �-�
`
fioi5 departme,nf. ADDRESS� LOCALI7Y ' "`��� �
� � - , . - -.. �'k..._. . . � NEAREST
�Dale � � Applimnt i�V ZIP CROSSST.
CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BL�GS. ASSESSOR a
� COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT � MAP e00K PAGE PARCEL �
� {This secfion nead not be complered if the permit is for one � .. .� uSe zONe MAP V
, -hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. �y
. � . TEL SPECIAL �� � � �
I<ertify that in ihe performance of the work for which ihis OWNER' � NO. CONDITIONS _. � .: tL
permit is i�sued,I shall nai employ any person in any manner � , ,• � �ISTRICT GROUP TVPE �- FIRE PRO�ESSE�6V y ,
, so as to 6ecome su6�ect fo fhe Workers'Compenspiion Laws. ADDRESS � � � : � . COry$Y, .�Z-�pNE ,_ OC i
_ t•-r d :, ' ti�'� 1�;,.�`+.k;.;, i��, �`.� .�',c., a
OC
.Date Applicanf C�TY Z�P STATISTICALClAS-IF1 ATION � APT CON00. O
� NOTICE TO APPLICANT: If, ofter making this Certificafe of ARCHI7ECTOR TEL . ��� d I
�Exemption, you should 6ecome subject to the Workers' ENGiNEER NQ CLASS NO. DWELL.UNITS_ ,� I
- Compensation provisions of the Lobor Code,you most forfh- �
- wifh comply with such provisions or fhis permit shall be ADDRESS SEWER MAP i-
' deemed revoked � TE�� gK, pg, VALIDATION
CONTRACTOR NO.
•. LICENSED CONTRACTORS DECLARATION . , ���,
I hereby affirm tho�I om licensed under provisions of Choprer 9 AooeE55 � NO. � VAWATION �
(commencing with Section 7000)of Drvision 3 of the Business and ��� � t : ....-.•
Professions Code,and my license is in full force and effect. CITV � CLaSS 8 -- ►
. �SQ.Ff. NO.OF NO.OF CHECK '
License Number �' Lic Class � SIZE STORIES FAMILIES ONE -
$
•� Coniractor'� � Date � DESCRIP710N OF WORK N� O ���
AD� �::.f,..F
❑I am exempt under Sec �� �--,y_
ALTER � FINAI , �w a c.�..,
8.&P.C.for this reason DATE ..., .
REPAIR � .� a g-'.,�t
. . Date: EXIST�ING B�DG.'i � DEMOL � PINAI . '"�",
. . . . �..........»_a-�... .. .........»_.,_ .
� Signature . .: � .. ._ . APPIICANT ii-��; i�; . ._ . TEL BY ,ro�r L ��:;�'L:T�,'
-�OWNER-BUILDER DECIARATION PRIN7) ,+�v ' NO � ��
I hereby affirm thot I am exempt from the ConlraUor's License . ... . " � . ' '�' i S ?"���k
Law for ihe following reason(Section 7031.5, Business ond ADDRESS
. Professions Code): PRE EN �
. � I, as owner of ihe ro erf or m em lo ees with BUILDING �
p p y, y p y ADDRE55
. ages as their sole campensation,will do the work ood
- the sfrucfure is not intended or offered for sale(Section LOCALITY
7044,Bosiness and Professions Code). MOVING TEI.
�� I,as owner of ihe property,am exdusively coniracfing C NTRACTOR NO.
with licensed coniractors to wnstruct fhe project(Sec- qD�RESS � -
tion 7044,8usiness and Professions Code). �S���'j�`f.,
REqUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCV SET BACK YARD HWY PROP.LINE WIDTH ,, � r�.�,a� �
I hereby affirm that there is a construction lending agency for PRONT , �" . �
� the performonce ot ihe work for which this permit is issued P.L. 2 �
(Sec.3097,�Civ.C.). . SIDE - .�l_�;�,^�d�;„2�
P.L.
Lender's Name ._ _ ��•�t.;u��1�.�.
$ P.C.Fee$ Permit Fee � �
Lender's Address u 1 ,;t�5
>
I certify that I have read fhis applicofion ond siate fhot the Issuance Fee '� -
¢ above informafion is carrecL I agree fo comply with all Coumy Invesligation Pee . �
g ordinances and State laws relating to building construction, ioiai Fee �
i"i and.he�eby authorize represen�atives of this County to enter
� opoh¢ha�-above-meniioned property for inspection purposea. f
� }��� ''` �'� ' ?�� - � I , � SEE REVERSE FOk EXPLANATORY LANGUAGE ,
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