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
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