Loading...
HomeMy WebLinkAbout1354A 4708A (7)8 b b WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, o %c rtifiedd.c oppy thereof (Sec. 3800, Lab. C.) icy oL_/uLOmpany 5-d 1[11 IY•s Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion epa nt. Date b gpplicant.Cf'? CERTIFI TE 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 shalt not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Dote Applicant NOTICE TO APPLICANT. if, after making this Certificde 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 1 am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professbns Code, and Im y license is in full fatforceandeffect. License Number _Lic. Cla 7 Contractor /N/1 s ,/61W & Dote O1 am exempt under Sec. B.&P.C. for this reason Sittgna ure NE U ECLARATION I hereby affirm that m xe 1 from the Contractors License Law for the follow ng r (Section 7031.5, Business and Professions Code): 1, as owner of the property, or my employees with wages as their sole compensotion, will do the work and the structure is not intended or offered for sole (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.). 7 Lender's Nome Lender's Address I certify that I have read this application and stale that the above i nformation is correct. 1 agree to comply with all County ordinances and State laws relating to building construction, - ond hereby authoriz presentative3 of this County to enter upon hove- oned property for inspection p s suSignreof m or Agem %% e APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL iN BUILDINGADDRESS BUILDINGADDRESS LOCALITY NEAREST CITY ZIP CROSS ST. NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT BLOCK LO7 NO. USE ZONE P S OWNER NO. FSkIAL NDITIONS - ADDRESS DISTRI47-. GROUP TYPECON J ZO PROCESSED BY ZO " r/l' o ' " CITY 151 ARCHITECT OR ZIP TEL, STATISTICAL CLASSIFICATION APT. CONDO, ENGINEER IVO, CLASS NO. DWELL. FJWTS.„_ ADDRESS SEWER MAP CONTRACT T BK. PG, VALIDATION Y ADDR rye CiI LIC. 3J AJr1 CITY z LIC. CLASS VALUATION 4 SQ. FT. NO. OF SIZE NO. OF CHECK t 1 % {Il CJ STORIES F ILIES ONE E ere•23 DESCRIPTION OF WOR NEW ADD eC1i.20 ALTER FINAL p e s 21 LL 2 0 REPAIR DATE, LS'- OFEXISTINGETIN rcr nn DFMOL © By FINAL - L U 2- C a _ c.4 SEE REVERSE FOR EXPLANATORY LANGUAGE es olna•-" w'n CN Y'i'p „1.3 00 .E ` °•: G.as it R' C '. [ y ,v y Z'S G . ?Z` •` Fp C 'C^,ti G •w . K i ' {, V o X• £ h , c d = o, _` c .r c` : 1 .s d 3 r c , E .' , •` a ,,, 1 e ' _ t, . r" , t e, .'.. .. k y d •w v ' .`^.• is : C tr. :. `_• is . G. O.' J ., • ti •N^. i^ _ G V J G S 17