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HomeMy WebLinkAbout0845A 2994AWORKERS' COMPENSATION DECLARATION y affirm that 1 have certificate of consent to self _, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT certified copy thereof IS— 3800, Lab, C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ."olicy No.—Compony Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING !� i(�� (� ❑ADDRESS Certified copy is filed with the county building inspec- BUILDING p Ci' (D�:J� h tion department. ADDRESS {� G(r' 1-41 Date Applicant / CITY 1 ZIP �OJ LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' y j NO. OF BLDGS. - NEAREST COMPENSATION INSURANCE SIZE OF LOT <' Now ON LOT („! clto55 5i. (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100) or less.) TRACT 23 BLOCK LOT NO. Ca MAP BOOK PAGE PARCEL I certify that in the performance of the work for which this TEL if OWNER CaTC Lr1. 1 t} , TEL L1 " 'ti / USE ZONE MAP NO. l� 14-S permit is issued, I sholl not employ any person in any manner y` ADDRESS 4��� ! ��� q'o(� SPECIAL. so as to become subject to the Workers' ompe sation Laws. CONDITIONS O •�%a6CTY�vG? U -"te nt ppca NOTICE O A LICANT: If, after ma ingihis Certificate of ARCHITECT OR _ TEL. ,,, / c�ey �• ENGINEER © 72 Y/1 NO. �riC1' cp DISTRICT GROUP NPE FIRE PROCESSED BY O you should become subject to the Workers' Compensation Labor Code, forth- i ( S CONST ZONE (I –) V provisions of the you must ADDRESS "'—' t with comply with such provisions or this permit shall be deemed revoked. TEL b CONTRACTOR P/:. NO. STATISTICAL CLASSIFICATION C APT. CONDO. (n U) LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL UNITS_ Z I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS S _ NO. `�� (commencing with Section 70DO) of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY–a0-t!'L G CLASS VALIDATION SQ. FT. NO. OF NO. OF Z. CHECK BK. PG. License Number Lic. Class SIZE d STORIES FAMILIES ONE Contractor Date /._/ DESCRIPTION OF WORK N 4/ � Y CJar NEW ❑ VALUATION $ �� 6 I Seca j ADD ❑ � , am exempt under ALTER 1/ 4.5 a 0B.BP.C. for this reason _• n + r d Ala", REPAIR $ 4 • • ° ` 23 Dote: USE OF k 'r' •/ EXISTING BLDG. ° rc:Ts•fi l d DEMOL ❑ d }( =..� OWNER -BUILDER DECLARATION TEL, APPLICANT . PRINT0 i FINAL y DATE 7' iSignature I hereby affirm that I am exempt from the Contractor's License 7" 7 �� � � pf4w. Law for the following reason (Section 7031.5,. Business and ADDRESS �/ J I�,j'�d f - cwt r FINAL Professions Code): PRE EN 2?.6 a By ❑BUILDING I, as owner of the property, or my employees with ADDRESSilioll `-' ze wages as their sole compensation, will do the work and •-� 6 ,{. the structure is not intended or offered for sole (Section LOCALITY ✓ • '✓°N • 7044, Business and Professions Cade). MOVING TEL. .�.�I, as owner of the property, am exclusively contracting CONTRACTOR NO. n with licensed contractors to construct the project (Sec- liar,7044, Business and Professions Code). ADDRESS 2 9 9, 4 A CONSTRUCTION FENDING AGENCY REQUIRED TOTALSETBACK FROM EXIST. SET BACK YARD HWY pROP. LINE WIDTH ° .. I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE �f Lender's Nome !! w f^� •t r+ Osvl LDMA Ref. k Lender's Address I'. C. Fee 5 Permit Fee 1 certify that I have read this application and state that the Issuance Fee �f% LDMA P/C If , above information is correct. I agree to comply with all County q ordi ce and State laws relating to building construction, Investigation Fee yy r7 Total Fee J 6,J 'moi a hereb authorize representatives of this County to enter LpMq perm. N pan the bove-mentioned prop ty for inspection purposes. 6 SEE REVERSE FOR EXPLANATORY LANGUAGE �. Signature o Applicant or Agent Do 4z L -Z3 t2 3t 7z