HomeMy WebLinkAbout1506A (8)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Compony
0 Certified copy is hereby furnished.
C] Certified copy Is filed with the county building in'spec- -
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(This section need not be completed if the permit is for one - --
hundred dollars ($100) or less.)
I certify that In the performance of the work for which this
permit is Issued, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making'thts Certificate of
Exemption, youshould become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked. - ..
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number Lie Class-
Contractor Date
I am exempt under Sec.
B.SP.C. for this reason _
Date:
Signature -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License -
Low for the following reason (Section 7031.5, Business and
Professions Code):
21, as owner of the property, or my employees with _
wages as their sole compensation, will de the work and
the structure is not Intended or offered for sole (Section
7044, Business and Professions Code).
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Cade).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued -
(Sec. 3097, Civ. C.).
lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. f agree to comply with all County
ordinances and State lows relating to building construction,
and hereby authorize representatives of this County to enter
upon a oboe -men ion C property for inspection purposes.
Signature Applicant or Agent - Dote
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
AnnRus
BU DING�1
ADDRESS or OJ JO /Yi
v L'r
9/
CITY r
ZIP
LOCALITY 44 •
"
SIZE OF LOT
NO. OF Bi` GSS
NOW ON LOT I
•
NEAREST.
CROSS ST. ,i 4/ctoA
_
~,e,
ASSESSOR
TRACT 3BLOCK
LOT NO.
MAP BOOK
PAGE
PARCEL
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TEL.OWNER
NO.r
USE ZONE
MAP NO / O
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S 333
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ADDRESS:;b D SS i •
SPECIAL -
CONDRIONS
'
CITY.
ZIP
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ARCHITECT OR
TEL.
DISTR!CT
I GROUP
I TYPE
FIRE
OCE SED BY
ENGINEER
NO.
nn
3
CONST.
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ADDRESS
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TEL.
STATISTICAL CLASSIFICATION
APT.
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NO.
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CLASS NO. � DWELL. UNITS
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ADDRESS
NO.
SEWER MAP
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CITY
CLASS
BK PG
VALIDATION ,
SO. FT. NO. OF NO. OF
CHECK
SIZE O STORIES
FAMILIES
ONE
VALUATION-
DESCRIPTION OF WORK - -
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NEW
-
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ADD
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ALTER
rave
REPAIR ❑
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USE OF
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APPLICANT TEL.
PRIM /S
L NO.
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- DATE 7J
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ADDRESS
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LOCALITY
MOVING TEL.
CONTRACTOR
NO.
ADDRESS
REQUIRED YARD HW1' TOTAL SETBACK F
SET BACK PROP. LINE WIDTH
FRONT
-PA.-
SIDE
P.L.
LDMA Ref. R,
P.C. Fee $ - -
Permit Fee -"
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Issuonce Fee - O
LDMA P/C R
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Total Fee
Perm. R
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