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Home My WebLink About8581A 1601A 1602AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certi; hereoff ( Sec. Lay Cs ian Insurance, or a certified copy Policy No. Company Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This section need not be cosy pleted if the permit is for one ohundreddollars ($100) ) I certify that in the performance of the work for which thispermitisissued, 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, offer making this Certificate ofExemption, you should become aobject to the Workers' Compensation provisions of the Labor Code, y nonsorthispermit shall bewithcomplywithsuchProv" deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9commencingwithSection7000) of Division 3 of the Business andProfessionsCode,' am full force and effect,0 License Numbers Lic. Class — r Conrracr Date . 1 am exempt from the licensing requirements .is I am a licensed architect or o registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code). Lic. or Reg. No.._------ Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's LicenseLawforthefollowingreason (Section 7031.5, Business and Professions Code): I, as owner of the property, or my employees with ages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section s 7044, Business and Professions Code). I, as owner of the property, am exclusively contractingwithlicensedcontractorstoconstructtheproject (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY y affirm that there is a construction lending agency forrormanceoftheworkforwhichthispermitisissued 7, Civ. C.). ass a dove read this application and state that the Q as is correct I agree to comply with all County J uSte laws relating to building construction, e r esentatives of this County to enter Grd property for inspection purpose 6 I -- 31L- I or AGS__ OS OF CITY W APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY VAS SE R f1 pp, FPARCJ1LFORAPPLICANTTOFALLINK ] y N 'vLIA !_, e ZIP GGNO. OF 81DG5. f Ito SIDEP.L. P.C. fee $ Permil Fee j f' G Issuance Fee I ' S Invest gouon Fee "7/`off Total F - SEE V SEE REVERSE FOR EXPLANATORY LANGUAGE z8591A j 23 I • 1 24.00 12€1 F 07.0#1. 81.2c 1 = •64,80 64.80 0218-82 z16Q2A 1 •224.50 224.50 0218-82 USJNO VALUATIONALUATIONOO 0,90 OT NO. 0. TEL. !3 / C- SPECIAL D OO CON TtONS O NO. DISTRICT GROUP TYPE FIRE PROCESSED BY U n=L_—,4./NEW CONST ZONE pE ALTER STATISTICAL CLASSIFICATION APT. DO. LJW TEL 3 NO. DWELL. UNITS__ D' NO. /O 3 A.D CLASS SEWER MAP - Z to LPG. VALIDATION Ito SIDEP.L. P.C. fee $ Permil Fee j f' G Issuance Fee I ' S Invest gouon Fee "7/`off Total F - SEE V SEE REVERSE FOR EXPLANATORY LANGUAGE z8591A j 23 I • 1 24.00 12€1 F 07.0#1. 81.2c 1 = •64,80 64.80 0218-82 z16Q2A 1 •224.50 224.50 0218-82 VALUATION ALUATIONOO0,90 LIC. n=L_—,4./NEW ALTER NIDATE D REPAIR EMOL Fe1NAL _ _ IO . Ito SIDEP.L. P.C. fee $ Permil Fee j f' G Issuance Fee I ' S Invest gouon Fee "7/`off Total F - SEE V SEE REVERSE FOR EXPLANATORY LANGUAGE z8591A j 23 I • 1 24.00 12€1 F 07.0#1. 81.2c 1 = •64,80 64.80 0218-82 z16Q2A 1 •224.50 224.50 0218-82 i v .Q _4+ g w S A " m - - - - - - - -