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HomeMy WebLinkAbout1201A 1427A (6) rv�as5��.s�-°�' , WG�KERS'COMPENSATION DECLARATION � �"' � �� ���� � � `� � " � I hereby af4irm fha� ' hove a cerfificote of consenf lo self APPLICATION� FOR BUILDI�NG PERMIT � insure,or a certificate of Workers'Compensation insurance, or cerrified mpy thereof(Sec 3800,Lo � ) � COUNTY OF LOS ANGELES BUILDING AND SAFETY Po,ic� � Company '�L'L � Certified copy is ereby furnished. � FOR APPUCANT TO FILL IN ' euaouvc . ❑ A�DRE55 Q �� Certified copy is filed wirh the county building inspec- gUaDWG tion depaMmeni. ADDRES �p �� Date `+' —n"" Applicant� CITY � ` ZI7 �� �. LOCALITY 1 CERiI�EXEMPTION FROM WORKERS' NO.OF BLOGS. NEARE57 - COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT GROSS ST. (This section nead nof be completed if the pe�mit is for one TRAR ' �� g�OCK LOT NO. ASSESSOR ' hundred dollors($tOD)or less.) ' NAP BOOK � PAGE PARCEL TE �y USE ZONE MAP I certify tha�in the performance of tha work for which�his OwNER � �,f NO, N� ��T��� permit is issued,I shall not employ any person in any monner � SPECIAt � sa as to become subject fo the Workers'Compensolion Laws. ADDRE55 --�.� o a CONDITIONS o CITY /-!/j�a ZIP j � U Date Appli[anf ARCHITECTOR 7EL. 7/y� � NOTICE TO APPLICANT: If, afrer making this Certificate of _ DISTRICT GROUP TYPE FIRE PROCESSED Bv O Exempfion, yoo shoold bemme subject to the Workers' ENGINEER D c/!'sva�NC. NST. L ZONE 1— Compensotion provisions of�ha Lobor Code,you must forth- ADDRE55 c� 1�'Y �ft�� W with comply with such provisions or Ihis permit shall be 7FL.7� STATISTICAL C1A551F1 ATION APT. CONDO. � deemed revoked. CONTRACTOR '2 . ,c�re, NO. i7' z UCENSED CONTRACTORS DECIARATION ���. ~ CLASS NO. DWELL.UNITS I herehy affirm that I om licensed under provisions of Chapfer 9 ADDRE55 � �'�R � Na� �" J SEWER MAP�- (commencing with Section 7000)of Division 3 of rhe B�siness and LiC. � rofessions Code,and my license is in full force and effect. ci7Y �;t, Cu55 BK � VALIDATION Sa.FT. NO.OF NO.OF CHECK License Num6er' � V f' Lic.Closs�_ SiZE STORiES FAMIUES ONE . � �// VALUATION� �Contractor',9�/lMn..e��i��i-,r�Date �%� J • DESCRIPTION OF WORK ✓ NEW ❑ S �J SC�� � ADD � , JJJ�❑1 am exempt unde�Sec. �� '��0� ALTER � � B.BP.C.for ihis reason REPAIR � s �� �Q I {a. Date: USE OF EXISTING BLDG. - DEMOI ❑ o � , APPIICANT ' y' . , TEL. i�/J �T° °C J Signature FINA OWNER-BUILDER DECLARATION PRINT) '/tJ 2' ' G ' �� 1 DATE ��Y � ° @�`�J�=� I here6y affirm ihat I am exempt from ihe Contractor's License Law for fhe following reason(Seciion 7031.5, Business ond ADDRE55 FlNAL s r. o U,.S,�.O�s,. Professions Code)� T - By ❑ BUILDING G[i C�—�S�i I, as owner oi Ihe property, or my employees with ADDRE55 wages as their sole compensation,will do ihe work and ' Ihe strocture is not intended or offered for sale(Section LOCALI7Y ?044,Business ond Prafessions Code). � MOVING TEt. � I,os owne�of fhe properfy,am ezclusively contracling CONTRACTOR NO. wiih licensed contra[torz to con5lruct ihe project(Sec- ADDRESS �ion 7044,Business ond Professions Code). ��� /�_�,�� CONSTRUCTION LENDING AGENCY SE7�BACK YARD HWY TQT'4A�S�T�A�NE WiD?H I hereby affirm thof!here is a consfrutlion lending agency for FROM 'pj� o.a s o o 'j rhe performance of the work for which this permit is iswed P L f e �J i ;J (Sec.3097,Civ.C.). SIDE P.L. Lendar's Name � °, �E I, .+J u g� LDMA Ref.k ` Lender's Address P.C.Fae 5 :� Permir Pee �.-1 ..�,i'-C;+ ' ��t C�_�,� � I certify that I have read rhis appiicafian and stote that the issuance Fea 1� •�� �oMa aiC N above information is correcf.I agree to comply wifh oll Coun�y Investigm�on Fae ,/ �. �� ordinances and State lows reloting to building consirocfion, 7a�o1 Fee S••3 IUM,�perm.N and hereb urhorize reprasenrotives of this County to enter upon a ve-mentioned pro ty for inspecfion p�pose�6. - ^ t d' ; /I �/ � J'� SEE REVERSE fOR EXPLANAFORY IANGUA6E ignar�re of Applicont or Agenl Dote .«m ......,:..,�� _ . a:+'s�R��..e:..�a.,. .,..__._.._.,w,._.......m._...._.._ .....a.. .�.. ....a....m.-....e...-,.�..�...�,.,.. .,,...w..�.....�...�..«a..�....�,. .....». . e...�...m...._....�..�.............«,....... 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