HomeMy WebLinkAboutNo Permit Number (1288)WORKERS' COMPENSATION DECLARATION
I hereby affirm ihct I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy Na. IMP,3ompany ztwlm
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
L'3 tiondepartment.
Date 3/9/" Applicant C. n bft
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
hundred dollars ($100) or less. )
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TOAPPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am I icensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number 239274 Lic. Class .131'3.
Contractor r`11111011$Fi Qi .S3, OCA& %eOS
DI am exempt under Sec.
B.BP.C. for this reason
Date:
Signature
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 compactors 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
35.
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 cansfru ction,
and hereby authorize represertiatives of this County to enter
upon, the pbbve-meet for inspection purposes.
54natare of Applicant or Agent Date
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN ADDRESS
BUILDINGADDRESS LOCALITY '
NEAREST
CITY rA aijil bar ZIP CROSS ST.
NO. OF BLDGS.
rp
ASSESSOR
SIZE OF LOT NOW ON LOT " l}' MAP BOOK PAGE PARCEL
TRACT 31353 LOCBK LOT NO. 101 USE ZONE OP i..- .
OWNER PrOOL7 Of so. Cal. N0.5.40--rJ",t 0
SPECIAL
CONDITIONS
L rs LL [[++....,, 00 Drive
DISTRICT GROUP TYPE FIRE PROCE55ED BY
ADDRESS `"4'•" CONST.—" ZONE
CITY 140111 DMIll z I P 9 2 G G,I
ARCHITECTOR TEL
STATISTICAL CLASSIFICATION APT. CONDO.
r
ENGINEER C WX106 NO. 0 1°^ $ CLASS NO. ' DWELL. UNITS !
ADDRESS SEWER MAP
TEL.
6K. CONTRACTOR T NO. FG,
VALUATIONd ADDRESS NO.)279
LIC.
CITY CIP.SST)"4
INO,STORIESOF .r
5 3' ECKCHONESIZE .ni.[s 'a" FAMILIES
FINAL
DESCRIPTION OF WORK NEW
fW11.1y (1,111111111im,
ADD
ALTER
Man 142— REPAIR E] DATE f ,,
FINAL
t F
USE OF
E%[STING BLDG. DEMOL
By
APPLICANT rto E BdiiatiKsPR
NTT
ariw NO..
ADDRESS "00 I1a;'1.X'!d N 'i X
INGSS
ITY
e, e
G TEL.
RACTOR NO.
SS
IRED .BACK YARD HWY PROP. LIN
WIDTHNTe
kADDRE
Permit Fee
Issuance Fee
igation Fee
Tocol Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
0
U
W
I.L.
T
at
0
G
H
its