HomeMy WebLinkAbout1506A 1507A (15)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, Lob. C.)
P$ y—��c-956-104—� ny ALTM
Certified copy is hereby furnished.
Certified copy is filed with the county building Inspec-
tion deportment.
Date 1/23/84 Applicant TfE AMEN GRMP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ffThis section ned not be completed if the permit is for one
{tundrad dollarse(:100) 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 Lows.
Data Applicont
NOTICE TO APPLICANT: If, after making this Certificate of
xemption, you should become subject to the Workers-
-ampensatian 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 'hot I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cade, and my license is in full force and effect.
License Number 370"Atl Lic. Class
Contractor `-LM ANfIEN GMIP DoteI Z2s3Zg4
13 1 am exempt under Sec.
B.BP.C, for this reason
Data:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
IJProfessions Code):
I, os owner of the property, or my employees with
4 wages os their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7014, Business and Professions Code).
nI, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7014, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm that there is a construction lending agency for
the performance of the work for which this permit is issued
_Sec. 3097, civ. C.).
Lenders Name
S
Lenders Address
I certify that I have rood this application and state that the
above information is correct. I agree to comply with all County
ordinances and State lawsr acing to building construction,
D and hereby authorize repr __.fives of this County to enter
4 uporVe aAbovve-mention rty for Inspection purposes.
AMg
oV�
Signature Applicant or A Dots
4 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
Ao,RF 1
BUILDING
ADDRESS
LOCALITY
NEAREST
Cltt
ZIP 917SC,
CROSS ST, Hlr"R MMB
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT
NOW ON LOT
MAP BOOK PAGE
PARCEL
USE ZONE MAP
TRACT BIOCK
LOT NO.
NO. —eT
TEl
SPECIAL
OWNER THE ANDEN GIOUPNO
CONDITIONS
DISTRICT .GROUP TYPE 1.1&,
PROCESSED BY
ADDRESS
CONi.�
CITY CCELILZ .
ZIP
STATISTICAL CLASSIFICATION
APT. CONDO.
ARCHITECT OR
.TEL.
/
I
ENGINEER
NO
CLA55 NO, Q.47 DWELL 'UNITS
ADDRESS 314 N. FTRV
VE. ARCADT.A
SEWER MAP
CONTRACTOR
TEL
O.
7-9541
BK. PG,
VALIDATION
LIC
ADDRESS
NO.
VALUATION
CITY
Cw
$156,900
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DATE
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