HomeMy WebLinkAbout1308A (7)WORKERS' COMPENSATION DECLARATION
I. 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, 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 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 Num r 735 -Lie Class V `
Controcto Date
I amex 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. 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)-
I,'os owner of the property, or my employees withIwagesostheirsolecompensation, 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
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.1 -
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
OR APPLICANT TO FILL IN BUILDING 7 /
B
V `/
PG. VALIDATION
ADDRESS O+ `f-Uj d
G .j S U S ;
CITY 1lPc. UCCLAS SI I
1 LOCALITY
Q. FT. NO OF NO. OF CHECK
NEAREST
ltormoANl ZIP CROSS ST.
NO. OF BLDGS. /
LOT ON LOT
ASSESSOR
MAP BOOK PAGE PARCEL NOW
BLOCK LOT NO.
p
LFARCHITECTOR UeONE
NOPV'
2.A,Li-iADD
1e% C7-7cJ7V Of" SPECIAL
CONDITIONS
ALTER FINAL
ADATEPUSE
DISTRICT GROUP FIRE PROCESSED BY
N
ZIP
JTYPE
CONST. ZONE
43CTORTELSTATISTICALCLA551FICATIONAPT. CONDO.
R NO. CLASS NO. 02 DWELL. UNITS_
APPLIICAN7
CONTRACTOR Ll w, 11—P7 B
V `/
PG. VALIDATION
ADDRESy, {D /L- &X pNO.32-
CITY 1lPc. UC CLAS SII
VALUATION
i j--
Q. FT. NO OF NO. OF CHECK
SIZE ISTORES FAMILIES ONE
DESCRIPTION OF WORK NEW
OA/ 2.A,Li-iADD
ALTER FINAL
ADATEPUSEREPAIR pD
EXISTING BLDG. DE OL FINAL
APPLIICAN7 TEL. BY %,jj ^ 13 Q 8 A
PRINC! I -_ F7 NO.-
ADDRESS y D- ,- gf 0'
4350
BEWtbtNl
UILDINGADDRESS 43,505
LOCALITY
MOVING TEL.
4 -1-20-82
CONTRACTOR NO.
ADDRESS
REQUIRED YARD HWYSETBACK TOTAL SETBACK FROM EXIST.
PROP. LINE WIDTH
FRONTPL
SIDEPL.
P.C. Fee $ Permit Fee J
c v fVI„c= (
Total Fee 4 -?-5d
SEE REVERSE FOR EXPLANATORY LANGUAGE
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