HomeMy WebLinkAbout0881A (4) I WORKERS'COMGENSATION DECLARATION �
I hereby affirm that I have o ce�tificate of consan�to self APPLICATION FOR �BUILDING PERMIT
�insure,or a cerfificate of Workers'Compenstion Insurance,or
a certified topy the�eof(Sec 38W,Lob.C.) COUNTY OF l05 ANGELES .9UILDING AND SAFETY
Policy No. Company . �j� �
� Cenifled copy is hereby fumished. FOR APPLICANT TO FILL IN qo REss � � �/' �t � �
�+C!//t..�'",/�rV f�3��!J s ,r✓,
� �Cerlified copy i:filed with ihe county building inspec- BUILDING �,i-�;
tion dgPa�fm6n1. ADDRE55 IOCP.LRY � � .�
NEARE55
Data Applicani CI7V ZIP CROSS ST. f/ -
CERFIFICATE OF EXEMP710N FROM WORKERS' ND.OF eLDGS. ASSESSOR ,
� COMPEN$ATION INSURANCE SIZE OF lDT O NOW ON LOT MAP BOOK PAGE PAR�L .
�This section need nof be completed if tlie permit is for one USE ZONE � MAP �
hundred.dollars(5100)or less.) TRACT � e�OCK �or No. �No. 3 3 y
� TEL. SPECIAL y
I certify fhat in the performance of the work for which ihis OWNER NO CONDITIONS �
. p¢rmit is issued,1 sholl not employ any person in ony manner DISTRICT GROUP ivPE FIRE PROCFSSED BY V
ADDRESS CONST.
so as to betome sublec�to�he Workers'Compensation Laws. `Z �� � � O
Da�a Applimnf ��TM Z�P STAi15TICAlQA551FICATION _/�/ AM. CONDO. (~j
NOTICE TO APPLICANT: If, afier making thls Cartificate of - ARCHITECI OR TEL. ,n ,� T W
Ezemption, you should become su6ject to the-Workers' ENGINEER NO. CtA55 NO._�G_(�DwELL UNItS_ �
Compcnsalion provisions of tha Labo�Code,you musf forth- qppRE55 � SEWER MA7 Z.'
with comply wifh sucb provisions or fhis permit shall be jEi . �
deemed revoked. CONrRACroa -� No. BK.�� r�, YAUDATION
LICENSED CONTRACTORS DECLARATION LK.
I hereby offirm thot I om licensed under provisions of Chopter 9 ADDRE55 NO. VAWATION i
(commend�g with Sec�ioo 7000)of Division 3 of Ihe Business and LIC.
� Professions Code,ond my license�s�n futl force and etfect CITY C1A55 E �dL.�7yf„� I
SGt.fi. NO.OF NO.OF � CHECK �
License Number Lia Closs SIZE SiORIES � � FAMILIES ONE - �j
Co�«pctor pQ�e �ESCRIPlION OF WORK
NEW $ 1G�
� 1 pm exempt from ihe licensing requi�emeNs as I am a � ADO � � J]���� v �
litensed archifact or a re9istered professional enginaer Al7ER � FINAL �� �V
acting,in my professional mpocity (Sectian 7051, REPAIR � DA7E ^`� �
Business and Professions Code). u5e OF t�t
. � ExISTING BLDG. DEMOL ❑ F�NA� �"1 .F
. BY t
Lic.or Re9.No. Date APPLICANT ie�.
� ��� - OWNER-BUII�ER DECLARATION PRINi}- - ND�. /
I haroby affirm that f am exempt from fhe Contractor's litense . r'" '
law.for the followin9 ieason(Section 7031.5.Business and aooeess
Professions Code):. ' vRE E � . - p
BUIl01NG �€�'- � �•
I, os owner of Ihe properly, or my employees wifh ADDRE55
woges os their sole compensation,will do ihe work and ,'�,'ir��� �+ �
the structure is nat in�ended or offered far sale(Section �OGa�17Y - ,
7044,8usiness and Professians CodeJ. MOVING TEL � ��+ ���]��(.
� I,as owner of the property,pm excl�sively conlrpcting CONiRACTOR NO. •• .z 7 =
with lice�sed coniractors fo ronstruct the project(Sec qD�RE55 � � C C
tion 7004,Busineu ond Professions Code).
CONSTRl1CTION LENDWG A ENCY REQUIRED TOTAL SETBACK FROM EXIST. •S�G�T—F�
$EiBACK �ARD HWY PROP.IINE WIDTH
1 hereby aFfirm tho��here is a cons�ru - n lending agency for FRONT -
�he performance of the wo�k for ich th�s perm��is issued - p.i �
(Sec.3097,Civ..C.). . SioE
P.L.
Lender's Name w,
$ P.C.Fee$ Permit Fea �. "�./ �
Lender's Address
w i certify fhat I have read ihis applimtion ond sfa�e fhat the issu e Fee � . I
� above information is forrect.I ogree to comply wifh all CouNy Investigarion Fee ��� y {�
or inonces and State lows relofing to building construc�ion, Totol Fee J [��
on her ent tives of Ihis County to enter
� up � ab ve i ned o erty for inspection purposes. - �
< ��� " J SfE QEVERSE FOR E%GIANAiORY LANGUAGE
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