HomeMy WebLinkAbout1512A 1513A (13)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to salt
insure, or a certificate of Workeri Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.)
Pol,8Fro �`-956-1Q y AH'inTA
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion deportment.
Date1„r '3/8I4 Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
xemption, you should become subject do the Workers'
�ompensotion provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Prafessions Code, and my license is in full force and effect.
UcenseNumber 371580 Lic.Clors B —
ContratlorTHF. ANDFN t;RCYTIP Date7r/?A/R4
I am exempt under Sec.
B.BP.C, for this reason
Signature
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following rsoacm (Section 7031.5, Business and
1J
P'r'o�fessions Code):
/ I, as owner of the property, or my employees with
` wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7041, Business and Professions Code).
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
t$ec. 3097, Ci, C.).
lender's Nome
Lender'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 epresentotives of this County to enter
u e above -men nod property for inspection purposes.
Sign a of Applico Agent Date
J� APPLICATION FOR BUILDING PERMIT Il
COUNIY.OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
ADDRESS 24261- SEAQ DR.
BUILDING
ADDRESS
LOCl.IITY T)TAVnM BM
91 51.3A
NEAREST
CITY ZIP
CROSS 5T.
•�38a50�
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT NOW ON LOT I
MAP BOOK PAGE
PARCEL
USE ZONE
TRACT 33020 BLOCK LO7 NO. 20
NO.
TEl
SPECIAL
OWNER —
CONDITIONS
DISTRICT GROUP TYPE FIRE
PROCESSED BY
ADDRESS
-r
y CONST Z7-1
/o
CITY ZIP 724
✓
STATISTICAL CLASSIFICATION
APT. CONDO.
ARCHITECT OR TM 9-073
J
NO. ZP'f UWEU. UNITSINFER
SZAW
CLASS
ADDRESS
SEWER MAP
TEL.
PG,
VALIDATION
CONTRACTOR NO.
ADDRES51074 PAIM V31W DR. N0.373580
VALUATION
lC
cin o.nss B
$
SO. FT, NO. OF NO. OF CHECK
_
SIZE SFORIES FAMILIES 1 ONE
��,,RR QQ�j�
DESCRIP 10M WORK CDNSPRUC ON NEW
t
OF SINGIZ FAMILY HCMES ADD ❑
ALTER ❑
FINAL
I S $•i
1 5 L 2 A
REPAIR ❑
USE OF DEMOL❑
FINAL (`
4 • • • • 2 1
EXISTING BLDG,
. nr.. i.... rr, MIR_
Ry CY\ A .ice
_ -7 2 t 2
SEE REVERSE FOR EXPLANATORY LANGUAGE
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0213-84
91 51.3A
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1.38550
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