HomeMy WebLinkAbout1355A 4709A (7)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or as certificate of Workers' Compensation Insurance,
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Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion depart. t. /
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Data Applicant Alirz ll' A_I W
Taild)&E EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need no; 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 Lows.
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 offirm 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
4ndQL_jlLa o1 .,Liic[c. Class
Contractor xWa. 7 2y
1 am exempt under Sec.
B.BP.C. for this reason
Dote:
Signature d-ud----
OWNER -BU ER C TION
I hereby affirm that I am xempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, or my employees with
wages as their sale 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 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
JSec. 3097, Civ. C.).
lender's Name
s
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with oil County
ordinances and State laws relating to building construction,
and hereby authorizer "emotive: of this County to enter
UPC, th obove-ment' d property for Inspection pur acts.
Sig'wture aM or A;e Dat
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
SEE REVFASE FOR EXPLANATORY LANGUAGE
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FOR APPLICANT TO FILL IN BUILDING avv ShADDRESSc)-3(3
8UIlDIN
ADDRESS N LOCALITY ,D,/ r
NEAREST eDCITYZIPCROSSST.
NO. OF BLDGS. h ASSESSOR
SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
USE ZONE MAP
TRACT BLOCK LOTNO.I NO.
SPECIAL7 E/.pOWNERTO CONDITIONS
DISTRICT .GR PEFIRE PROCESSED BY
ADDRESS CONST. ZONE
p
CITY
ARCHITECT OR TEL
STATISTICAL CLASSIFICATION APT. CONDO.
ENGINEER NO. CLASS NO.DWELL. UNITS_,_
ADDRESSJ SEWER MAP
CONTRA
77 1&Wf, i 'No t' Y.% BK. PG, VALIDATION
uc.
ADIXiE L Lc N VALUATION -
CIN
LIC. b CLLASS d O QOd
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tSIZE D NO. OF NO. OF
STORIES
CHECK
FAMIUE ONE
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DESCRIPTION OF WORK NEW
2 3
t/!
ADD
ALTER11 FINAL o I• 1 1 7, 9 4
REPAIR 13DATE D
USEST 1 1 7, 9 4LJ
NG B DEMOL evNA
SEE REVFASE FOR EXPLANATORY LANGUAGE
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