HomeMy WebLinkAbout1784A WORKERS'COMPENSATION DECLARATION C�
� I heraby oft��m fho, � ha��a cerlificote of consent to sa�f APPLICATION FOR BUILDING PERMIT u
insure,or a ceriificate of Workers'Compensation Insuronce,
or a certified copy thereaf(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ BUILDING
Cer,ified copy�s hereby fumished. FOR APPLICANT TO fILL IN ADDRE 6�j . /Ll.�'!
❑ Cenified mpy is filed wilh the tounty building inspeo- gU1L�iNG
lion departmenl. ADDRESS � Q�Yl /�LjiKi
Date ApplimM CiT ZiP tOCALITY �. N�
CERTIFICATE OF EXEMPTION fROM WORKERS' NO.OF 6tDG5. NEAREST
COMPENSATION INSURANCE 5¢E OF LO7 NOW ON l07 CROSS ST.
(This seclion need not be completed if ihe permit is for one ASSESSOR
hundred dollars($100)or less.) TRACT 3� BLOCK LOT NO, MAP BOOK PAGE PARCEL
7E1. USE ZONE NOP U ��
I certify that in the performonce of the work for which�his OWNER NO. ,
permit is issued,I shall not employ any person in any manner qDDRE55 /Jk'�- �^�f7r�CONDITIONS Q
so as to becoma s�bject to the Workers'Compensation laws.
C>
�ate Applicant CITY ZIP �.
NOTICE TO APPLICANT: If, ofter makin fhis Cerfificpte of ARCHITECTO TEL ISTRICT GROUP TYPE FIRE PROCESSEDBY o
9 ENGINEER NO. .�r�1 CONSj.-� ZONE U
Exempfian, you should become subjett to the Workers' U �/
Compensation provisions of the Labor Code,you must torth- qoDRESS �� .J� �
with wmply with soch provisions or fhis permit shall be �"'
deemed revoked. TE�� STA ISTICAt C1A551FICA710N APT. CONDO. �
CONTRACTO NO. �•O'� ' 1 1 �
LICENSED CONTRACTORS DECLARATION p��y,,., '" ���, C1A55 NO.�DWELL.UNITS
i heraby affirm thot I am licensed under provisions of Chapter 9 ADDRE55 ptT/� NO.
(commencing with Section 7000)af Division 3 of the B�siness and ,��� SEWER MAP
� Professions Code,and my license is in full forte and effect. CItY � � Cta55 BK � VALIDATION
. SQ. T. NO.OF NO.OF CHECK
� License N�mber__Lic.Class SIZE STORIES FAMILIES ONE
VALUATION
� Confrattor �ote DESCRIVTION OF WORK NEW ❑ �1 /,�(4�
ADD s
�I �I am exempt under Sca � AL7ER � , ;�j o • o s C J
' B.BP.C.for rhis reason REPAIR s � s �a S��
USE OF
'� Date: EXISTING BLDG. E l ❑ e o u C�,��C�
I Signature AVP PR NT NO. � F�NA� � �
OWNER-BUILDER OECLARATION OATE �4�, 7�'�'�
�, I hereby afflrm that I om exempt from the Contractor's License
Law for the following�eason(Sectlon 7031.5, Business and ADDRESS FINAL
Professions Coda)� BY
� I, as owner of the properry, or my employees with aDDRE55 � � yl� ��
ages as their sole compensation,will do ihe work and ��. ,
Ihe slructure is not intended or offered for sale(Section LOCAIiTV w
7044,Business and Professions Code). � r�noviNG TEL. C��,
� I,as owner of fhe properly,am exclusively coniracting CONTRACTOR NO.
wilh licensed contractors to construct the project(Sec- � qpDRE55 j�
lion 7044,Business and Professians Coda�.
CONSTRUCTION LENDING AGENCY REQUIRED TO7AL SETBACK o
SET BACK YARD HWY pROP.LINE �N�OTH
I hereby affirm thaP there is a constr�ction lending agency for fRONT
the performance of ihe work for which�his permii is issued p.t.
(Sec.3097,Civ.C.). SIOE
P.L,
��. Lender's Nama /� r `,....,' tDMA Ref.#
P.C.Fee$ ,s�j s V V Parmit Fee ,
Lender's Address_
I cenify rhat I have read this applicalion and stale that the issuance Fea LOMA P/C#
a6ove informafion is conect.I agrea ro comply with all County Invesligmion Fea
�� o ordinonces and Stale laws rebtinq to building consiruction, To�al Fee LDMA Perm.N
and hereby authorize represenrotives of ihis Counly to enter
� �q upon Ihe a6o�e-mentioned properfy for inspeclion porposes. /�y f7
�� & SEE REVENSE FOR EXYLANAYORV LANGUAGE ►Ll.�s+-- C"�`.'►�— �
Signature o4 Apphmn�or Agent Dme J
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