HomeMy WebLinkAbout1061A (5) -. _._- . �_ . -... -------
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WORKERS'COMPENSATION DECLARATION � �
I here6y a(lirm 1ha1 I have a certificote oF tonsent�o self qpp��CATION FOR BUILDING PERMIT �
insure,or o tertifimre of Warkers'Campenstion Insurance.or ' �
o certiiied copy thereof(Sec 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � �
PolicyNo. Company '
� Ce�rfed copy is he�eby fumrshed. FOR APPUCANT TO FILL IN ADDRESS ' ' ' '" ,
� Cer�ified copy is filed wiih ihe coun�y building inspec- BWIDING� . , � � � � � � •/, ,
IiOn deparlment. ADDRE55 ' LOCALITY .
" NEAREST - '
Date ApplimM ❑iY '�'� � "' �- ZIP °� � C40S5 ST. � - - ' . }
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.O�BLOGS. a55ESSOR � . p.
COMPENSATION INSURANCE 512E OF LOT NOW ON LOT N:AP BOOK PAGE PARCFL " �
(This seclion need not be completed i(the permit is for one USE ZONE MAP _ ' . . U
. hundied dollars(5100)or less.� TRACT . BLOCK• LOT NO. , NO. ' ' , J
' iEL. � �� _� SPECIAL
pWNER ��' � ��- ' � � NO. ' �� ' CONDITION$ li
I cerlity that in the performance af Ihe work for which Ihis DiSiRiCf GROUP TYPE fiRE PROCESSED BY
pe�mit is iswed,I shall nol employ any person in any manner `' , , � }
� so as,�o become subject to ihe Workeri Compensa�ion Laws. ADDRE55 , CONST._- ZONE : . K
/J f ..._ , ; . • „ _ . /•. ... . .r. �. � Q
I:,f•'�, 1 .:� .' . . CITY ZIP , C
Date � Applicant ' � � SfAl15TICAt CLASSiFIC,.AIION API. CONDp, O
• NOTICE TO APPLICANT: If, afler making this Cerlifimle af . ARCHITEC70B TEL. „ � . a
Exempli0n, you should bewme subjecf fo ihe Worker5' ; ENGINEFR NO. CLA55 NO. OWELL UNITS �
Compensation provisions of the Labor Code,you must farih- qDDRESS $EWER MAP V� �
with comply with suth provisions or this permit sholl be ' '
deemed revoked. TE�' BK. pG, VAIIDATION �
CONTRACTOR NO. �
LICENSED CONTRACTORS DECLARATION iiC.
I here6y afti�m Ihat I am licensed under provisions oi Chopter 9 , AD�RESS NO. • VALl1ATION -
(commencing with Section 7000)of Division 3 oF ihe Business and LIC. �r .;.� -
Pro(essions Code,ond my license is�n foll force ond effe<�. I CiTV ctnSS S � •� - ��
50.FT. NO.OF NO.OF CHECK � .
license Number Lic.CIa55 SIZE STORIES.. FAMILIES ONE � '
' � New ❑ �� s �
COnifOC10I Date � DESCRIPiION OF WORK , . , .
❑ . . : ADD, � � . ..
I am ezempl from Ihe licensing requirements as 1 am a
licensed o�chitect or o reg�stered professionol engineer ntiER Q t+ FINAL �
ocling in my pro(essionol copacily (Section 7051, REPAIR � I DAtE a� '` �
Bosiness and ProFessions Code�. USE OF ::,1.�•c'�,� I�,
EkiS711.G BLCG. DEMOI ❑ � FINAL (� �
LIC.or RBg.No. - Dole APPIICANf . . . � . TEI." . BY �L !;.0,R��'.�.�
OWNER-BUILDER�ECLARATION (PRINT) n10. ' � � , . . ^ .
I hereby o(firm�ha�I am exempt from the Convoclor's License , . , '�-.',"-�,��:e!.;.
law foi ihe�o�lowin9 rrason(Section 7031.5,Business and ADDRESS ' �
ProFessions Code): r�wwi � .'.°.'��� l.:.1.�.i�
BUILDING' �
� I, as owner of the properiy, o� my employees wiih ADDQESS ' . �.'.��� ,
wages as their sole compensa�ion,will do the wo.k ond � � i
. r.�.��1�!�
ihe strucrure is nat intended or oifered for sole�Sedion LOCALITY„/ �-
7044,8usiness and Proiessions Code). MOViNG��' ' TFI. ': • .
� I,as owner of Ihe propeny,om eaclusively Co��rocting CONTRAC�'OR :.JO'�. ' �
wilh licensed conlraclors 10 conslrucl Ihe project($ec- qDDRE55��� � ' �- s�����
lian 7044,Business and Prafessions CadeJ. - - ,. -
CONSTRUQION LENDING AGENCY ' RE�UiRED� . TOi7+15E18nCK FROnn ExiST. - -
SET BACK�..' �ARD . HWV CROP.I���E WIDlFi
I here6y affirm Ihol�here is o mnstruclion lendinq agenty far FRONi' - � � .
� the performance of ihe work for which ihis permit is issued a� �
. (Sec.3097,CIv.C.}. SipE 1� ; �, _y.I�
- P.l. -/.: ��. •
f
Lender's Name .
$ Lender's Address P.0 Fee 5 � ;s�1'. �«�i f •• ' ' �
W I certify thot I hove read�his opplirotion and slate Ihat ihe� R � ce Fee' " I
above informotion is torrect I agree to mmply w�lh oll Counry invesr�go��an Fee '-• ' � � ''��� •
$ ardfnonces and Sate lows relaiing io building tonslruclion,� �;�.',, �,F� ..' /• - ' ',i.. � •�
and hereby o�ihortze represenlolives of this County lo enter� ,
I m upon the obove�menlioned properry for inspection purposes. , � �. ', . , ;, , '
�a` - • - ., . � �� - ' . � SCEFEVERSEfi�ll�L�►t�NATORYIANGOAGE . I�k;, �
I� Signoiure of Applicant or Agen� Do�e ' .. . �.�.'� F,., �..f!•i`i,,�•� 9�r.
t,. ,i. ..'__