HomeMy WebLinkAbout1510A 1511A (15)WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified cop thereof llSe00
c. 38, Lab. C.)
Policy No —CRC-956-1(�40;�EA,A
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date VZ34134Applicant THF, AADEN !_=]R
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($10D) 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.
Date Applicant -
NOTICE TO APPLICANT: If, after making this Certificate of
xemption, you should become subject to the Workers
�...-ompensotion 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 Business and
Professions Code, and my license is in full force and effect.
License Number 3715$0 tic. Class B
Contractor rITTF' AbIDENT t^_=TP Date 4/")3/.8
T
I am exempt under Sec.
B.&P.C, for this reason
Date:
Signalure
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
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 Name
Lenders Address
I certify that 1 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 authwi representatives of this County to enter
up the above -m 'Dred property for Inspection purposes.
AA A
Sigmt al Applin a Agent Date
(� i3 APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
BUILDING
ADDRESS
LOCALITY DIAMM BM
NEAREST
CITY DTAMCM RAR
ZIP 91756
CROSS ST.
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT
NOW ON LOT
MAP BOOK PAGE
PARCEL
USE ZONE
MAP
TRACT 2 BLOCK
LOT NO.
21
J %
OWNER
NO-9541
SPECIAL
CAL
CONDITIONS
DISTRICT GROUP TYPE - FIRE
PROCESSED BY
ADDRESS
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