HomeMy WebLinkAbout6563AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab. C. )
Policy No. Company
Certified copy is hereby furnished.
�,,-Certified copy is filed with the county building inspec-
tion de arfm nt•
Date f�� J Applicant. de"
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
r: hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you'• should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revgked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 2 % U' '' Lic. Class ¢
Contractors} `Z`''�""' % Date c!�
ElI am exempt from the licensing. requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
Lic. or Reg. No. Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the aboye='mentioned property for inspection purposes..
Signature of Applicant or Agent Date
5
APPLICATION FOK WILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESSBUILDING
ADDRESS f �Pr-r % ' 3 3' s f ✓
LOCALITY f 4V{ '
CITY f5t)C ZIP
CROSSS T.
NO. OF BLDGS.
ASSESSOR
SIZE OF LOT NOW ON LOT
MAP BOOK
PAGE
PARCEL
TRACT/
BLOCK LOT NO. f
USE ZONE
MAP r
NO.
OWNER% a (' '- TEL.
NO. U�-
SPECIAL
CONDITIONS
a
DISTRICT
GROUP.
7
TYp,�F,:: try
FIRE
PROCESSED B Y
;>
ADDRESS p a r r r'%'" yf
C6NST.
ZONE.
CITY ; 7 1 ZIP'Jf�
ARCHITECT OR TEL.
STATISTICAL CLASSIFICATION
7
APT ,.
CONDO
ENGINEER d !' i NO.
CLASS NO. DWELL. UNITS
ADDRESS
SEWER MAP
BK. PG, VALIDATION
VALUATION
$
CONTRACTOR NO TEL. 7 D
LIC.
ADDREss294 u r d7 � - NO. l
CITY, CLASS
SO. FT.
NO. OF
NO. OF
CHECK
SIZE
STORIES
FAMILIES
ONE
$
DESCRIPTION OF WORK 9 r : }
NEW
ADD
FINAL
', ',
REPAIR
DEMOL
DATE
FINAL
B y
USE OF
EXISTING BLDG.
APPLICANT TEL.
(PRINT) NO.
-3
ADDRESS
``; ` 3
/
a 7
PRESENT
BUILDING
ADDRESS
u f
LOCALITY
MOVING TEL.
CONTRACTOR NO.
�$'• •',�l.•'I
,r•i
D
YARD
HWY
TOTAL SETBACK FROM
EXIST.,
K
PROP. LINE
WIDTH
rADDRE
Permit Fee i
Issuance Fee
on Fee
` �r
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
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