HomeMy WebLinkAboutNo Permit Number (57)I
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, ora certificate of Workers' Compensation Insurance,
or a certdied copy thereof (Sec. 3800, Lob. C.)
Policy No. Company
Certified copy is hereby furnished
Certified copy is filed wilh the county building inspec-
tion deportment.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one,
hundred dollars (3100) or less.)
I 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 become subject to the Workers Compensation Laws.
Doter (
I 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 am licensed under provisions of Chapter 9
commencing wi•h Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number. tic. Class
Contractor Date
1 am exempt under Sec.
B.BP.C. for this reason
Date:
Signoture
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):
I, as owner of the property, or my employees with
wages as their sole compensation, will da the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
1 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.).
tender's Nome
Lender's Address
1 certify that 1 have read this application and state that the
obove 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.
I Signature of Appticanr or Agent Do'e
APPLICATION FOR BUILDING PERMIT 0
COUNTY OF LOS ANGELES BUILDING AND SAFETY
SEE REVERSE FOR EXPLANATORY LANGUAGE •f. `• I v
FOR APPLICANT TO FILL IN auMINGADDRESS
BUILDINGADDR
CITU t I Dv LOCALITY
NO. OF 8LDGS. NEAREST
SIZE OF LOT NOVI ON LOT - CROSS ST.
ASSESSOR
TRACT ( BLOCK LOT NO. t J MAP BOOK PAGE PARCEL
OWNER: TE1ND.O. USE ZONE MAPNb. I
SPECIAL 1, I
AGGRESS CONDITIONS
CITY ZIP 1 '
ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY
ENGINEER NO. I CONST. I ZONE
ADDRESS` I
TEL. STATISTICAL CLASSIFICATION APT. CONDO.
CONTRACTOR NO.
CLASS NO. DWELL. UNITS ILIC
ADDRESS NO.
LIC.
SEWER MAP
CITv CLASS BK. M. VALIDATION
SO. FT. NO. OF N'O. OF 1+ CHECK
SIZE STORES FAMILIES 1 ONE
VALUATION
DESCRIPTION OF WORK NEW [j`(^ y. iADD
ALTER 1
REPAIR S v
USE OFEXISTING P.LDG. CFMOL
FINALAPPLICANTTEL.
IPRINT'i i I NO. f ,
DATE
ADDRESS FINAL
By l1 IL^.(r
PRL LN
BUILDINGADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
o+ • G FLADDRESS
HWYUIiiiiTOfAPROPSEIB v
SE108ACK YARD LINE WIDTH
I'n' FRONT
P.L. h G.
a c, ! ! 2 5SIDEP. L.
LDF.W Rel. M
P.C. Fee S I { 1 Permit Fee _ ! ,' ' !
popInunnteFees!' +/, r': LWAA P/C R
Invesugwt Fee _• :
Total Fee Perm, !I
SEE REVERSE FOR EXPLANATORY LANGUAGE •f. `• I v