HomeMy WebLinkAbout1850A WORKERS'COMPENSATION DECIARATION � - �
APPLICATION FOR BUILDING PERMIT �
1 hereby affirm ihat I have a certificate of consem to seH
insure,or o cerlifitate of Workers'Compenstion Insurance,or �
, o cerii(ied copy ihere�of(Set.3800,Lab.C.) COUNTY OF LOS ANGELES BIIILDING AND SAFETY
f�`. i1:
�PolicyNo.' Company . 1 . .
� Ce��iRed copy is hereby fum�shed. FOR APPLICANT TO FILL IN bUILDiNG � - i I �
ADDRESS
� Certified mpy is filed with the counly 6uilding inspec- BUILDING i;.i,//�I � v � � '
. Iion department. nDDRESS � a ����''�1` lOCAllrv
.,.1:=�-: �:� '� NEAREST ' .,
� Dole �.-� � ` Appliconl �� ' "' CiTY�` - '� ZiP CROSS ST. � � � }
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. n55E5SOk y
� COMCENSATION INSURANCE SIZE OF tOT NOW ON tOT MAP BOOK PAGE 7ARCEl �
�This secrion need no�be comple�ed if ihe permit is for one ..,;�'�k . f uSE,ZONE MAP V
hundred dollars(5100)or less.) iRACT ' ' I BLOCK ior NO. �' , NO. � '�' � '. y�
� I cerlify that in the performance of Ihe wo�k ior which�his
OWNER �%!-.f•� '4�t, ��' �� ' NO.j�'1'� �I �I I � J CONDIilONS � IL
,permil is issued,I shall no�employ any perton in any monner � �. �.'L+ `I � :_ 1 DISiRICI GROUP iVPE � FIRE PROCESSED BV � ).
� so os ro bemme su6ject io�he Workeri Compenso�ion Laws. nDDRESS � � � �� �V �� CONST. -��� 2CNE � K
UTY 1...��..i�l;.; ':. %'J':. 21P 1 � ��� _� J I .•.' , . . / � Lr
. �a�e Appli[Onl STATISTICAL ClA551fICA1tON APT. CONDD. ' O
NOTICE TO APPLICANT: If, a(ter moking Ihis Certificote of /RCHRECi OR-� � . 7EL:, . .,;�_1,� ��}� � ; p,
.Exemption, you should bemme s�bject ta the Workers' ENGiNEEQ NO.�- - CLASS NO. DWELL UNITS �
Compensalian provisians of Ihe La6or Code,you musl fonh- ' .' j. . � � � � W
with comply wilh w[h provisions or this permit sholl 6e ADDRE55 '. SEwER h1aP F-
deemed revoked. ',.,{,;�`. . , tE�. `�.�1 : �K p� VAIIDATION
CONTRACTOR NO. ' ' '
UCENSED CONTRACTORS DECIARATION �,_ r •
+' ,:� '�..;�::_�:�:: ' liC.->,. � . .
I herebyatfirm tha�1 om licensed under provisions of Chapter 9 ADDRE55 • - �-���'�NO.�-- '��� VALUATION � .
(mmmencing wfth Section 7000)of Division 3 oi the Business and - ��C. . �
Professions Code,and my license is in full iorce and ef(eU. U7Y �^'�" �-������ -� C1A55 �"t`, S`^- �`��
S(].FT... j NO.Of � NO.OF CHECK
License Number Lia Cioss SiZE �• �� STOR!ES FAMI�IE$ ' ONE '
NEW � S
GOnIraC�or pa�e DESCRIPTION OF WORK: � _ • �
� I om eaemp�from ihe licensing requiremenis as I om a = .�1� � ��- �- � AD� , ;
licensed archilect or a registered professiona�engineer AUER � FINAL .
ocfing in my professionol capacily (Section 7051, ❑ DATE
Business and Professions Code). REPniR .
. USE OF FINAL
E%IS71NG BIDG. DEMOL ❑ B .{��,t:��:�n'
y ���7'.
� Lit.or Reg.No. Date APPLICANT iFl.
OWNER-BVIIDER DECLARATION (PRiNTI NO. �' r„�'s�a�a• �.
- I hereby af(irm�hal l am e�empl iram Ihe Controdor's License - - -� - -- - - - - - - - -- - - - ��•�-�_;;,-��_ - - -
Law For Ihe iollowing reoson(Section 7031.5, Bvsiness and AODRESS ,t;d,�,�•��•j��
Professions Code): rR���N; •, � :-
aBUILDiNG !,�';,�,u l,w•l:(i,
I, as owner af the property, or my employees wiih ADDRE55
wo9es as Iheir sole mmpenso�ion,will do ihe work and �r:;
ihe strutlure is not imended or oftered for sale(Sedion �OCnuiv , .�,�:�.,,�.c.
7044,Business ond Prafessiom Cade). MOVING iFL . �
� I,os owner of the properly,am exclusively conlracfing CONTRACTOR NO.
wilh ficensed conrroctors to conslrucl the projecl($ec- ADDRE55 �
tion 7044,Business and Protessions Code). ' .
CONSTRUCTION LENDING AGENCV REOUIRED yARD HWV T�TA�SETBACK FROA1 ExiST.
SEi BAIX FROP.IINE VlIDiH
I heiebyaffirm ihot there is o consuuc�ion lending ogency ior FRON7 '
the performonce of Ihe work for which Ihis permil is issued p� . -
, (Sec.3097,Civ.C.). SIDE �
P.L.
lender's Nome �
� P.C.Fee S Permil Fee ' `��" '
Lender'z Address �
W I cer�ify ihof I hove read Ihis applicalion and state Ihal the issuonce Fee ` ��
aabove informotion is mrrect.I agree�o mmply with all Counly Inves��go�w�Fre ,
^� ordinances and State laws reloting to building conslruclion, Totnl Fee � � '-' '
and hereby aulhorize representalives of Ihis Counly to enter ,
¢ vpon thr.above-merilioned property for i�spection purposes.
a �!��� . -� ���� ' ' �� ' , "�r'('^ $EE REVERSE FOR EXPLANATORY IANGUAGE
r Signa�4Je o�Appl��ant o�Agent Do�e � 'P�
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