HomeMy WebLinkAbout1515A (8).. WORKERS'COMrENSA ._,.... _. ._ _. ... ..___._.-..._..._.._.._._. .._ .. ._..._.-..�._. ..__...-._...._.. ... ._.. _---..._ _.__. ___. _..._._.__._.
r TIO N ' DECLARATION _
I hereby affirm phot I hove a certificate of consent to self
insure, or p certificate of Workers' Compensation Insurance, - �- APPLICATIONS FOR . BUILDINGTERMIT----��
oFacertified copy thereof (Sec. 3800, Lob: C.) - - - -"
,. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No, . Company - -
Certified copy is hereby furnished:' '
C6r'tified copy is tiled with the county building 'inspec- ' Icon department.
Date. Appllmnt
CERTIFICATE OF EXEMPTION FROM WORKERS' "
COMPENSATION INSURANCE I' -
(This section need not be completed if the'permit ii for one - --
hundred dollars ($100) or less.) .
certify that in the. performance of the work for which this
permit is issued, I shall not employ any person in any manner _ -
so as to(�be�c�o�me iu�bj�ect to the Workers' Coinpensat*Lo
Date_iL=1�L'Q�Appl icantNOTICE TO APPLICANT: If, aftermaking this Certie
Exemption, you' should 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 Bvsinew and _. .
Professions Code, and
my license is to full Force and effect.
License Number v� F65 Lic: Cldss' •' 12:�= I' .
CoMrodor�ro2 rTf 6-h �n16FfEe U-I'o�'o /
I am exempt under Sec.-"-
B.BP.C. for This reason
Signature-
NER-BUIL ER DECLARATION -..
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
"Professions -Code):
Ti— 1, as owner of the property, or my employees with _ -
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
-- -7044, Business and Professions Code).-
1, as owner of the property, am exclusively contracting
-- with licensed contractors to construct the projecY(Sec-
tion 7044, Business and Professions Code).
- - - - - -- - CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
-the performance Of the work for which thispermitis issued ----
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
..I certify.that I hove.read this application and slate thatthe
above information Is correct. I agree to comply with all County
_ ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS
CITY11 IAA r\
ZIP
LOCALITY
i
. _ .. ... _ .. _
NO. OF BLDGS. ....
- _....
NEAREST _
. _.._. _. __._
. v.....
SIZE OF LOT
NOW ON LOT
CROSS ST.
ASSESSOR ,. .--
-j
"- _ -
...
TRACT BLOCK
LOT NO.
MAP BOOK -
PAGE
PARCEL
OWNE -
TEL.
N
_
USE ZONE
PJ0
J
`--
ADDRESS i '--"---
SPECIAL -
PECIAL.ADDRESS-
CONDITIONS
,
ZIP
ARCHITECT OR
TEL.
DISTRICT.._
GROUP.
TYPE
_
� FIRE
PROCESSED BY
ENGINEER
NO
R 'L,
__
CONST.
Z NE
-.1A
ADDRESS
---
1 s J
-
T L f
STATISTICAL CLASSIFI TION
APT.
CONDO.
CONTRACTOR
.ao�'!J J
T `
CLASS NO. DWELL UNITS
ADDRESS
tJO.
SEWER MAP
LIC.. --
CITY _
CLASSBK.
�.--"'"'-"--
--
"VALIDATION ---'
SO. FT
OF NO. OF
_ CHECK
SIZE
INC. _ _
STORIES
_ _
FAMILIES
ONE
- VALUATION
" •'"'•
' '" '�-.
DESCRIPTION OF WORK
-"
NEW--
= V V
20a�
,
`
`=1 5 1.511- .
ADD ❑
;
'.
li •. .o : ,( ,.
ALTER ❑
REPAIR--❑
.. .._i. ..._.
..�_.. .._
( -3675
USE OF
DFMOL ❑
EXISTING BLDG.
FI NAL
DATE--
- - -
�
••• 3 6 7 5 ?�
APPLICANT1
(PRINT
ADDRESS
C
FINAL"'
—BY
PRESENT
BUILDING
ADDRESS..
1_„•. �:(^•
_ :j f r- �'-�I.!t
-
.�
LOCALITY
MOVING
CONTRACTOR
NO.
"
-
ADDRESS
. REQUIRED LOTAL SETBACK M -EXIST.'
'YARD HW1'
SET BACK
PROP. LINE
WIDTH
-"•
FRONT
SIDE,,
.. P.L.
DMA Ref. N
',:. ... .
2L
P.C. Fee E ... .. .....
Permit fee
•.
... _.. .__._..... ....
Issuance Fea"LDMAP/CN--_
i
Investigation fee
Total Fee--
COMA Pernf'N
upon the obove-mentioned perry for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANG AGE
ignature of Applicant gent-- - - ... Dote...
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