HomeMy WebLinkAbout6644A (18)WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I hove a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Compony
P Certified copy is hereby furnished.
ElCertified copy is filed with the county building inspec- tion deportment.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for onehundreddollars ($100) or ]am.)
I certify that in the performance of she work for which this
permit is issued, I shall not employ any person in any mannersoostobecomesubjecttotheWorkersCompensationLaws,
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate ofExemption, 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 bedeemedrevoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions ofChapter 9
commencing with Section 700D) ofDivision 3 ofthe Business and
Professio. Code, and my license is in full force and effect.
License Number Lic. Class-
Contractor lanContractorDate
ClI am exempt under Sec.
B.BP.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor'sLicenseLawforthefollowingreason (Section 7031.5, Business andProfessionsCode):
1, as owner of the property, or my employees with
wages as their sole compensation, will do theworkand
the structure isnot intended or offered for sale (Section
7044, Business and Professions Code).
1, as owner of the property, am exclusively contractingwithlicensedcontractorstoconstructtheproject (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency fortheperformanceoftheworkforwhichthispermitisissued
Sec. 3D97, Civ. C.).
Lender's Name
Lender's Address
1 certify that I have recd this application and sate that the
above information is correct. I agreeto comply with all County
ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter
upon the obove-mentioned property for inspection purposes.
P Bignaturo of App4conf or Agent Data
APPLICATION FOR BUILDING PERMIT Il
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDINGADDRESS
BUILDING 2AiADDRESSeZQLOCALITYK r
y CITY J )L ZIP NEARESTCROSS5T,
NO. OF BLDGS. ASSESSORSIZEOFLOTNOWONLOTMAPBOOK PAGE PARCEL
TRACT BLOCK LOT NO. USE ONE MAPNO.
OWNER45&A/ TEL. NO. O SPECIAL
CONDITIONS
ADDRESSSS 3rd S d. u. DISTRICT GROUP TYPE
CONST. FIREZONE PROCESSED BY
JCITY,[f J %Z. ZIP f!H'T
ARCHITECT OR TEL, STATISTICAL ClAS51FICATION APT. CONDO.
ENGINEER aE J ANO CLASS NO. DWELL. UNITS_
ADDRESS /j i ts:tv<,L A, SEWER MAP
CONTRACTORT TEL. G NO. BK. PG, VALIDATION
LIC. ADDRESS 61iti:. 4 C..-=1 D NO. VALUATION
CITY LAA. P CLLASs
SO. FT. NO. OF NO. OF CHECK
SIZE STORIES FAMILIES ONE
DESCRIPTION OF WORK NEW S
ALTER FINAL
O - REPAIR C] DATE
USEEXISTING BLDG. DEMOL FINAL
Rv 6 6 4.4 A
Fee
TEL.
Tobi
SEE REVERSE FOR EXPLANATORY LANGUAGE
x....23
1••2500
2a00E
1 1.06-84
DIVWI DF BUILD ANDSA1•LL t
DlpaxwlEm of Y
APpij V8D
UNDER ORDIF E No. N• &
y w 6 684
j TIIts Mt fP1Ene
itts. 0 4 it
1110M
Nddl to ptall [Imssane n Is rmleeiul to tnsN! 4at Elttwit, s -I- elhoUtMermilstonttatnen! .Dian pi IiexEutE
N•
Maelgnm
0Tth1tp En ee0l{RilalhWBpnl ffIA LfbrfreltlEtepplrmlertapslnsp1plloftMNnr11fgyitensofELBiCCU" {{row
es
It zz
n y a ` mr°.tlo
C •, G w y M
Om
w`
m a G is
T p U y ,` . N y •:+ ., o u 4. a
T Up3o7.'w 'r :w .'.` + Y. m`r_•
O C 'Cr n
Vc 1
d
Ory `yn{wmk c r _
C
0 3 L ; ' w -c c o c ti :t ,. 'i Y ^•
c
c -,. `. e: Cl
VA I
Z3D ." .: rr _ Y" C ... y
7: 0 i~` C N c ; "C' C x c m c
Cr"•,
G v v r `- r. . V
c. = ot cu
a
k C C k Kc, • w O SSTOO> r o +
N ti •Ct "w C r..•
4 6
K
1 w a
6 c G C
p C n 1 4 •"
k41 'y, ti c,. c ti 1
J ' C w$ S itl. •w C::z G
i