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HomeMy WebLinkAbout1463A (8) WORKERS'COMPENSATION DECLARATION C . • `` ;;�;ebo�a'�e,�<<o'�eo,woke,-'�omPe�Sa°�o���=��a��e` APPLICATION FOR .BUILDING PERMIT � or a cerlified cop Iher f 5 0 Lab.C.) ' � �- ' � ._, J COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Polic omp6ny . ' , � � � eru ied copy�s hereby furnished. � FOR APPUCANT TO FILL IN BUILDING � ADDRESS � Certiiied copy�i�filed with the county building inspec- "� " OUiIDING 7_ ,TJ� /� /� �tan depanmeM. ' nDDRE55 f� V N/> /� � Do�e - Applitant � . . CiTY II� D � i / ZIP...L I b � LOCALITY \ CERTIFICATE OF EXEMPTION FROM WORKERS' � �� � NO.OF BlDGS. NEAREST � . COMPENSATION INSURANCE � � . S�2E OP LOT NOW ON LOT CROSS ST.� (Thls section need nof be compleled if the permil Is for one tRAR�1 Y � BLOCK lOT NO. � MAP BOOK PAGE RCEL � hundred dollars(5100)or less.) .. . � �-- OWNER � �NO. I - /i � USE ZONE N✓+P `1 �i� I tertify thot in the performance of�he work tor which this � �� �� �Y y. permif Is iseuad,I ahall no�employ any person in any monner � SVKiaL il, -� eo oe to become subjact to the Worke�s'Campensotio ws. ; ADDRE55 � CONDITIONS p � '�L.V�I� /1 '_ Cltt���:/V+' .V� ZIG I � �' �ate� -��� AppliConl " ' • pgCHITECT OR _/ TEL.. ( DISTRICT GROUP TY7E FIRE PROCESSED BY O NOTICE TO AdPIICANT: If, aftar m�ing thif Cerfiflmfe of j � ENGINEER � +/V NO. 7��� Q CON T ZONE F"' ExempNon, yoo ahould 6ecome a 6�ec� to-the Wotkers'� � at /� � W Cempeneafion provielons of the Labor Code,yoV mVsl fOf117• A�pE� 2 f,J - ,% : �V a. wllh comply wllh such�provisions or thie permll shoil 6a TEL."/ STATISTIUI CU1 SIFI ATION APT. CONDO. Z deemed revaked. �. [ONTRACTOR NO.r� � IICENSED CONTRACTORS DECLARATION � - � ���,� M55 NO.�DWELL UNiTS � I hereby effirm that I am Ilcensed�nder provisions of Chopfer 9 ADDRE55 NO. i ��R�P (mmmencing wirh Sattlon 7000)ot Dlvision 3 of Ihe Buelneu ond . . ���, . ' � Pretes�ions Code,and my Iicense I�In full force ond effect. Cltt MSS BK � VALIDATION - � � � SQ.FT. +� NO.OF NO.OP GMECK - LicenieNumber Lte.Clasi � � SIZE STORIES FAMIlIES ONE - VALUATION DESCR�PTION Of WORK - N� � � Controcfar�. . Date � ADp :, , �I am exempt under Sec, ALTER ❑ � � B.BP.C,for thi7 reason . REPAIR ❑ s � � � � Date;-� � USE OF � CEMDL ❑ ExISTING BtDG. Signvt�re APPIICANT J TEI. F1NAL OWNER-BUILDER DECIARATION PRINT NO. DATE 1 hereby affi�m that 1 am exempt from tha Controctorb License , law for Ihe following ieason(Setlfon 7031.5,Bu�tness and /+DDRE55 FINAL Pro leeions Code): ' � � � ' � -� �� � rv �y :?1 4 6 3 A � BVIIDING 1' I, as owner of the properly, or my employeee wHh aoCRESS , +� ' wages as�heir sole campensation,will do the work ond n a a a o a'� the structure is nof infended or offered tor sale(Sectlan ����Tr � 704e,B�stness ond Professtons Coda). MOviNG - TEI. t � � � � , .I • � 4�J.�� � I,as owner of the properfy,am exclu�fvely conlracting CONTRaC70R NO. : with Iicensed tantrodore to construct tha prajact(Sec• AODRE55 � '� • 1 4 a 0 0 u tion 7044,Businass and Professlom Code�. O � �V REQUIRED TOIAL SETBA K � • D 9.0 8-8 8 -� -�� CONSTRUCTION LENOING AGENCY SFT BACK YARD HWY PROP.UNE WIDTH � 1 here 6y o f fi�m t ha�t here is a cons truc tion leri ding a g e n c y f o r fRONT Ihe performance o(ihe work fo�whith Ihis permH is issued P.L- � � - (Sec.3097,Civ.C.). SIDE ' , P.l. lender's Nama . � \, LDMA ReL M ---- V.C.Fee S - Permil Fee , tender's Address I certify thel I hove read Ihis opplicaiion and s�ate thet the . Issua�ce Fee �`O� lOAM P/C X obove informalion is correU.I agrea lo mmply with oll Couny Invewgation Fee /�� ordinances and Sta�e laws rala�ing to building tone�ruc�lon, Toial Fee 1 l�l L�MA Perm.N and haraby autharize ro resanla�ives of this County to enter � opon the ebov�maN n�d p�operty for inspection porposes. !/(���.,�/� ��E��� � SEE REVfRSE FOR F7(PIANATORY LANGl1AGE � Signofure of Applicanl or,AgeM� � Dote . . . . . . .. (/ z � 0 0 � T b. ?' � . i-'O -ry. �'7 p C iG , .s\. � r .(1-p R'6, O �. . 0. ..O S �:. � ��� �O ° o � � �+ o � � s , r ' -ir O n p �� � . ..� v v ` �.� .''1 d r R' ^� .o � ry O ' t° � J y . 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