HomeMy WebLinkAbout1637A 5332A WORKERS'COMPENSATION DECLARATION `�
I her,eby affirm fhat I have a certificate of consenf�ogelf APPLICATIQN FOR BUILDING PERMIT
� insure,or o certificate of Workers'Campensation In urance,
or a certifie copy ihereof(Sec.3800,L .C.) o,)...t�Kv\�
�;�,� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N � ' ���Compan BUILDING !`\ y,,� �
. � Certified mpy is he�eby furnished! FOR APPLICANT TO FILL IN ADORE55 �r7� W ~�.J�
� Cartified copy is filed with ihe county building inspec- eUILDING y� �, (�1�
tion d por ent. ADDRESS �) � �OCALITY ��Ck1 �_
NEAREST
ote � Appllcan � ' UiY - zIP CRO55 Si.
C IFICAiE OF EXEMPTION FRO WORKERS' ;� � NO.OF BLDGS. nS5E550R
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be compleied if ihe permit is for one � �i--- uSe zoNe n�P r�� �v
TRACT BLOCK LOT NO. "� NO. 1 �
hundred dollars($100)or less.) �I �.�
iEl. SPECIAL
I certify that in the performance of the work for which ihis OWNER , j � NO.i'f" � ' P� C9� CONDITIONS �
DIS ICT GROUP TYPE FIRE PROCESSE�BY �
permit is issued,I shoil not employ any person in any manner • ^� i � CONST 2 � Z''
, so as to became subjecf to Ihe Workers'Compensation Laws. ADDRESS ' . - � �o �.,
I CITY ' � ZIP �" �� � r .�i
Date Applicant $TATISTICAL CLASSIFlCATION APi. ONDO.
� ARCHITECT OR � TEL. �
� NOTICE TO APPLICANT: If, ofrer making this Certificate of ENGINEER ,� -� NO.�"����^� ;s�^�7 CLq55 NO. ��� DWELL.UNITS�'
� Exemption, you should 6ecome subject to �he Workers' �a
Com ensafion rovisions of ihe Labor Code, ou must forih- �- t i �f'��'� SEWER MAP
P P Y ADDRESS � �=j �
, with comply with such provisions or ihis permit shall ba TE� f
deemed revoked. CONrenCTOR i �" ` } NO.�uf� - BK.1�PG, � VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
i I hereby affirm that I om licensed under provisions of Chapler 9 ADDRE55 7 NO. VqIUATION
(commencing with Sedion 7000)of Division 3 of ihe Business and r, , ���.
� Professions Code,and my license is in full force and effect. Ciiv (__.' ' aA55 $ ►
� � � SQ.FT./%"�t}�"' NO.OF f^� NO.OF 7 CHECK
License Number Lic.Class SIZE � � STORIES �= FAMILIES 7 ONE
i , '"' ' L7���='7 r NEW S .-�� I �;J. �R
Coniractor Date �E S C R I P TI O N O F W O R K
I C:!_ /.' .Y %!C.. AD� � #e o • a C S
� I om exempt under Sec. . � � FiNAL s���,•.�R
ALTFR
EB.&P.C.for ihis reason � � �W '' '� ��- REPAIR � bAYE ;��' A � m C��(-;Z 'c,`
j Date: USE F -� DEMOL ❑ BINAL n �C C�.��z
5 �. EXISTING BLDG. �<� Y
+ Si noture APPUCAN7 -� TEL._.,
g OWNER-BUILDER DECLARATION PRINT �� NO.�J' r��j�/� 'J�L � I'"C>4
1 here6y affirm ihat I am ezempt from the Contractor's License �4... � ,
Law for the following reason(Section 7031.5, Business and + ADDRE55 ..7
I Professions Code): PRESENT 7
BUILDING ���_'„�
I, as owner of the propeity, or my employees wifh ' ADDRESS
� wages as their sole rompensation,will do the work and
fhe sfructure iz not intended or offered for sale(Sectian �OG4�ITv
7044,Business and Professions Code). MOVING TEL ��'�J,�'ti,
� I,as owner of the property,am exclusively contracting CONTRACTOR NO.
wilh licensed mntracfors to construcf the project(Seo- n �* Q a a � � �
tion 704A,8usiness and Professions Code). � nooke55
REQUIRED TOTAL SETBACK FROM EXIST.
! CONSTRUCTION LENDING AGENCY SET BACK YARD HWV PROP.LINE wiDTH � I�! U J G'C
� I hereby affirm that there is a convruction lending agency for pRONi , � ��.
the parformante of the work for which this permil is issued P.L ° ��,f -1 3O l�o
� (Sec.3097,Civ.C.). . -SIDE � � � �
j m r.�. 0 E�.c 1 '�8 4
� lender's Name ��I
I $ Lender's Address P.C.Fee$ �� Permi�Fee ` ��5
I � I certify Ihat I have read this applicolion ond stale ihat the Isso ce Fee lv�`
m ahove information is correct.I agree fo comply with all Counfy Inves�igotion Fee �n
�Ig ordinances and State laws relating to building construction, Total Fee � o
. � and hereby_ ulhorize rapresentatives of this CouNy lo enter
� upon t e ove-mentioned property for inspection purpos s.
g\ �- � SEE REVERSE FOR EXPLANATORY LANGUAGE
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