HomeMy WebLinkAbout1308AWORKERS' COMPENSATION DECLARATION
I. hereby affirm that I have a certificale of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lob. C.
Policy No. Company
El Certified copy is hereby furnished.
Certifiedcopyis filed with the county building inspec-
tion department, '
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-
ith camply with such provisions w 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 Num r 735 -Lie Class V `
Controcto Datezwl L'_
1 am ez pt m the. licensing requirements as I am a
license architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No.-Dote-
OWNER-BUILDER
o.DateOWNER-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,'os owner of the property, or my employees withIwagesastheirsolecompensation, will do the work and
the structure is not intended or offered for sale (Section
7044, 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
t 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
aabove information is correct. I agree to comply with all County
ordinances and atelaws relating to building construction,
and eby a _rise representatives of this County to enter
6 u n ob e -mentioned property for inspection urpo e,
ign a of Applicant or Agent ,
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IJUDDREILDING 7 /
g PG, VALIDATION
DRESS Os `f_Uj d
BUILDING .j S U ALITYADDRESS ;
CITY VPc.
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ASI
VALUATION
SQ. FT. NO OF NO. OF CHECK
REST
CITY iV'WJON ZIPOSS ST.
NO. OF BlDGSSESSORSIZEOFLOTONLOTPBOOKPAGE
PARCELTRACT
NOW
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OWNERISTRICTO"V SPECIALCONDITIONS
ALTER
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D ZONECITY43ARCHITECTORTELT.ITLCAL CLASSIFICATIONENGINEERNO1A55NO. 02 DWELL. UNITS_
APPLIPRCANT
CONTRACTOR Ll ui, NO. 8(-7 7 g PG, VALIDATION
ADDREICT, /L EaZ NO. 3
CITY VPc.
CLIC
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ASI
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SQ. FT. NO OF NO. OF CHECK
SIZE STORIES FAMILIES ONE
DESC IPTION OF WORK NEW
OA/ N ADD
ALTER FINAL
DATE`- REPAIR pD
USE
EXISTING BLDG. DEMOL FINAL
APPLIPRCANT TEL. By /„ 13 Q 8 A
C! NO.
ADDRFSS n r s
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4 3 5 0
BUILDINGADDRESS 4 3.50 5
LOCALITY
MOVING TEL.
CONTRACTOR NO.
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PROP. LINE WIDTH
FRONT
P L.
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P.C. Fee $ Permit Fee J
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Total Fee 4 -?-5d
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