HomeMy WebLinkAbout1675A 5328A (225) � WORKERS'COMPENSATION DECLARATION ry
� ha,abY affirm thal I have o cer�ifica�e o,consem,o se�F APPLICATION FOR BUILDING PERMIT ��
insure,or a certificaia of Workers'Compensation Insurance,
or o cer ed c'o1py thereof(Sec.3800, a�b.`C.n) CpUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyN� "{�bf�ampany �`U�U��(V�� eUI�DING
� Certified copy is hereby fornished. FOR APPLICANT TO FILL IN ADDRE55 :� «�d c_e �'+ �-��..:
� Certified copy is filed with the county 6uilding inspec- eUIIDWG..�-�.�_ � ,.,-� ' � J
fion(�ep fineni. �y AD�RE55 � �' LOCAIITY �+'�{. �..�.d��
/y ��I� NEAREST
Date llpplicant �✓C� �,a��/ CITY � � '� ZIP CROSSST. °•'���"��-�
CE IFICATE OF EXEMPTION F WORKER3'✓ �ry O.OF BLDcs. n55E550R
COMPENSATION INS ANC��y�� SIZE oF tOT „J NOW ON Loi MAP BOOK PAGE PARCEL
� (This secfion need not 6e completed if Ihe permit is for one � r�C ' ,+ �,„ USE ZONE MAP . � ) �•
hundred dollars($100)or less.) 7RAGT .� ���� eLOIX LO7 NO. �,.'.,.+ �� ND. � t3 �' .J�
� . TEL SPECIAI
� I certify that in the performance o4 the work for which ihis OWNER NO., C ��'��°� CONDITIONS ��,.
ermit is issued,I shall not em lo an erson in an manner r DISTRICT GROUP TYPE FIRE PROCESSED BY �
� P P Y Y P Y ;, �ti.�' _. ,�. ;,,
so as to become su6jecf fo the Workers'Compensalion Laws. AbDRE55 ;� CONST. ZONE
`I,� , � %d.� � �
,� Dafe ApPlimnf CITY . Z�P STATISTICAL CLASSIFlCATION APT. CONDO. p•
ARCHITECT OR TEL.
NOTICE TO APPIICANT: If, after making ihis Certificale of �"') r��7 '+�
ENGINEER O.'�',�I��-� CLAS$NO.�_�WELL.UNITS_ ibS
Exemption, you sho�ld become subject to the Workers' �
Compensation provisions of the La6or Cade,you must forth- � :'�'�•�" •C-�-•f �� �•-- � '� SeWER MAP ''n
ADDRE55
with comply with such provisions or this permit shall be �
deemed revoked. TE�� t ' VALIDATION
� COMRACTOR NO.� - BK� �',
� LICENSED CONTRACTORS DECLARAiION ,. ��� �
I hereby affirm thai I am licensed under provisions of Chap�er 9 AooRE55 y(j f� , �_.'-''Ew � �-NO.�, %+G^ VAWATION �
� (mmmencing with Seclion 7000)of Division 3 of the Business and ��� z i b 7.5!,
Professions Code,and my license is in fall force and effect. �iTy ��q� �..(;<�� ' $ ��l�� , �� 8 q Y,�.�
/ ¢' y� SQ.FT�- NO.OF ' NO.OF CHECK�
� LicenseNUmbe��"�J�� Lic.CiaSs -CJ SIZE STORIES . FAMILIES ONE
� n /J/� , � I � a 25�00
k Conlractor�+'C�� �"�•lJ�W���Date � DESCRIPTION OF WORK s NEW o A ,�^
@ A�D
� �'�JU�Iu
; I am exempi under Sec . -� ALTER � FINAL •�` !��e, r�2^1 v E y,
¢ B_&P.C.for ihis reason � + - ��" �'�� � �'? REPAIR � DATE �`��' : . `
R �, USE Of
Da�e: � EXISTWG BLDG. .ry ' �EMOL � FINAL
� ' BY
Si nafure , APPLICANT . TEL.
9 OWNER-BUILDER DECLARATION PRINT) � NO.r, n
I hereby affirm that I am axempt from Ihe Contractor's License ,,�..,- ,
Law fOr the foilowing reason(Section 7031.5,Business and ADDRESSc �y� '�{ ' �=."•,'
F a:. .
p Pro4essions Code): P 7 o
¢ � i, as owner of the property, or my employees with ADDR 55 �����ry��
� wages as their sole compensafion,will do the work and ' ,
the siructure is not intended or offered for sale Section �OCAUTv ��
( z�32�A
7044,8usiness and Professions Code). MOVING iet.
� I,as owner of the propeny,am exclusively contracting CONTRACTOR N0. ` �a • o e a �
i ❑ with lirensed coMraclors to construct the projetl($et- qDDRE55 � m o 5 Q 5(�
� tion 7044,Business and Professions Code).
ttt REQUIRED TOTAL SETBACK FROM EXIST
� CONSTRUCTION LENDING AGENCY 5E7 gq�K vaeo HwY pROP.uNE WioTH ► b . ��,yO�
I hereby affirm that there is a construction lending agency for fRONi Q'$,�i —8(j
the performance of the work far which this permit is issued P.t. .
3 (Sec.3097,Civ.C.). SIDE
- P.L.
lender's Name (''�
$ P.C.Fee$ ��' � Permit Fee �J
Lender's Address
� I certif that I have read ihis a lica�ion and s�ate that the � ��
Y PP Issunnce Fee
� above information is correcf.I agree to comply with all Couny Imesrigation Fee
g ordinances and State laws relating to building construction, iowl F�e � ,r�a
� and hereb authorize representa�ives of this Co�nty to enier
$ �pon ove-m�e fone operty for inspection purpos s.
�� �/• / �/� r SEE REVERSE FOR E%PLANATORY IANGl1AGE
re o4 Applim eM, te �s
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