HomeMy WebLinkAbout1494A (8)L WORKERS' COMPENSATION DECLARATION
I hereby nflirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800. Lob. C.)
Policy No. Company_
❑ Certified copy is hereby furnished
Certified cap y is filed with the county building inspec-
tion deportment.
DateApplicant
CERTIFICATE OF EXEI,'.PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (S100) or less.)
I colli fy 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 become subject to the Workers' Compensation lows.
Date Applicant
NOTICE TO APPLICANT: IF, after making this Certificate of
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 om 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 Numbor Lie. Class
Contractor Date
17 1 am exempt under Sec.
B.BP.C. for this reason
Signature
OWNER-BURDER CECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law For the following reason (Section 7031.5, Business and
Professions Code):
I, 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).
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (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 this permit is issued
(Sec. 3097, Civ. C.).
Lender's Nome
tendei s Address
I certify that I have read this application and state that the
'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
upon the above-mentioned property for inspection purposes.
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
OR APPLICANT TO FILL IN
131.1110 G
ADDRESS /2
:NG7F55
I J .I�'L:i'If L -L-/.
,.LL
D/ Am Cr t. r r3A ZIP 9tifS—
LOCALITY
NO. OF BLDGS.
NEAREST
OF LOT NOW ON LOT
CROSSST.
�^s �7ASSESSORi •4 7 j % PIOCK LOT NO % r
P,%P BOOKPAGE PARCEL
ER _FAH E'S M. jLC 1-Tf FANO. c� (f -,� (. 7C
Ur.�EO-
3ESS
1 - L—
SPECIAL
CONDITIONS
D!!hF-tr Nr>/¢ZIP -7HITECTORrr
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INEER .)n C
GROUP
TYPE
CONST.
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ZONE
PROCESSED BY
REss 4f rSt)f?ruJs'TEL.
STATISTICAL CLASSIFICATION
APT.TRACTOR
NO
CLASS NO. DWELL. UNITSRESS
LIC
NO.
IIILIC.SEWER MAP
CLASS
BK PG VALIDATION
FT. NO. OF NO.OCHECK
STORIES FAM ILIFS
ONE
VALUATION
$ _ 1
UV
f el n. 4 r1
�; • s • C J
FINAL
DATE ) • e 2 7c
e o •2'7, e:'-7.
!
CESCRIPTICN OF WORK J Ii /: !y-
NEW ❑
ADD ❑
✓`t=7F)!N!r-4 Loi/FLL
y
ALTER ❑
REPAIR ❑
USE F
EXISTING BLDG. I-J'O f*L7
DEMOL ❑
APPLICANTTEL Joy-
(PRINT) �/sM: j M• S/ lr A'JSEN.. r!" - /' C• J
pa";HI%L QJP heu•F eAlzc1,
ADDRESS e�l'I)-
FINAL
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PRESENT9y
BUILDING
ADDRESS
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LOCALITY
MOVING TEL
CONTRACTOR NO.
ESS
ASEI
REQUIRED TOTAL SETBACK FROM XI ,
BA
SEl BACK YARD HWY PROP. TINE WIDTH
FRONT
P L.
SIDE
P. L.
LDMA Ref. N
?I
P.C. fee f ;29 - 6 Permit Fee rr,570
'
140's-0
hsuonce Fee
ID.MA P/C M
Invesngcro Fee
3 C)
Total Fen -
LD.lA Perm. M
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote
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