HomeMy WebLinkAbout1307A (7)WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab. C.)
Poli y No. Compony
Certified copy is hereby furnished. -
ElCertified copy is filed with the county building inspec-
deportment,
Date 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
Exemption, you should become subject to the Workers'
Compensation 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 ¢x.3735 Lie. Class_ '
Contracto
es
I am exempt from t to licensing require Is ./am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. Date
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):
aI, 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 1. 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—
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 author" arepresentatives of this County to enter
h vupoaboe ntioned property for inspection pu pose .
Si cur Applicant or Agent p
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
ADDRESS%O
PREBUILDINGADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
REQUIRED TOT,
SET BACK YARD HWY
FRONTPL
SIDEP. L.
Issuer
nvesagalion Fee
i¢tol
NO dPI-7177
FOR APPLICANT TO FILL IN BUILDINGADDRESS 1103 0 G f
BUILDINADDRE55:P a EFL K LOCALITY
e e e 31,505
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01,20-82
NEARESTCITY
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NO. OF BLDGS. ASSESSORS1ZEOFLOTNOWONLOTMAEPzzBOOK PAGE PARCEL
TRA K+ BLOCK LOT NO.
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DISTRICT GROUP TYPE PR ESSED BY
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ARCHITECT OR TEL STATISTICAL CLASSIFICATION APT, CONDO.
ENGINEER NO. CLASS tJO. DWELL. UNITS_
ADDRESS SEWER MAP
CONTRACTO TEL. NO. /7 BK. PG, VALIDATION
ADD E. LIC. NO.
LIC.
PALLIATION
7 K
CITY CLASS
SQ. NO. OF / NO. OF CHECK .
SIZE STORIES 1 FAMILIES ONE
DESCRIPTION OF WORK J Q d Y NEW
ADD
A,`4
ALTER FINAL
REPAIR C] DATE io i.1,?3
USE OF
EXISTING BLDG. DEMOL fINAI w }
ADDRESS%O
PRE BUILDINGADDRESS
LOCALITY
MOVING
CONTRACTOR
ADDRESS
REQUIRED TOT,
SET BACK YARD HWY
FRONTPL
SIDEP. L.
Issuer
nvesagalion Fee
i¢tol
NO dPI-7177
2-23'x/
1.•31.50
G e e e 31,505
TEL. 01,20-82NO.
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