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WORKERS COMPENSATION DECLARATION { w
t f
hereby affirm that I have certificate of consent self APPLICATION F®R BUILDING PERMIT
Insure or o certificate of Workers
ers Compensation insurance
or a certified copy thereof (Sec 3800 Lab C )
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company I
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county building inspec BUILDING & G
tion department ADDRESS
Date Applicant i I CIT (� ZIP t�
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NO OF BLDGS NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO ASSESSOR
hundred dollars ($100)or less ) MAP BOOK PAGE PARCEL
� TEL USE ZONE MAP
I certify that in the performance of the work for which this OWNER i' NO NO 7 4O 19
permit is issued I shall not employ any person in any mannert —� SPECIAL
ADDRESS +
so as too become sub ct to the Workers Compensation Laws CONDITIONS U
Date` Applicant ( CITY ZIP a,
NOTICE TO APPLICANT If after making this Certificat of ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE SSED BY O
g ENGINEER NO CONST ZONE r F"
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth ADDRESS + V ` U� 3 US
with comply with such provisions or this permit shall be TEL �`` ((�� STATISTICAL CLASSIFICATION APT CONDO
deemed revoked o CONTRACTOR NO Z:Z
LICENSED CONTRACTORS DECLARATION �M LIC CLASS NODWELL UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS
(commencing with Section 7000)of Division 3 of the Business and ��++ C SEWER MAP
Professions Code and my license is in full force and effect ' CITY IYL CLILA55 / BK PG VALIDATION
�`JO SQ NO OF NO OF CHECK
License Number D Lic Class SIZEFT STORIES FAMILIES ONE
VALUATION
Contractor Date 3—�� DESCRIPTIO OF WORK NEW ❑ $ 6l �QD
I �� ADD
I am exempt under Sec ❑
k ALTER
B 8P C for this re on IREPAIR ❑ s
Date USE OF p
EXISTING BLDG DEMOL ❑
Signature Z2 APPLICANT TEL FINAL
OW ER BUILDE D LARATION PRINT NO DATE
I hereby affirm that I am exempt rom the Contractor s License '
Law for the following reason (Section 7031 5 Business and ADDRESS F r�az Professions Code) r
❑ BUILDING
I as owner of the property or my employees with ADDRESS ^i
wages as their sole compensation will do the work and
the structure is not intended or offered for sale(Section LOCALITY
7044 Business and Professions Code) MOVING TEL
I as owner of the property am exclusively contracting CONTRACTOR NO
with licensed contractors to construct the project (Sec l
tion 7044 Business and Professions Code) ADDRESS
REQUIRED YARD HWY TOTAL SETBACK o t] 6 2`3 8
CONSTRUCTION LENDING AGENCY SET BACK PROP LINE WIDTH ti —+ *�P,
I hereby affirm that there is a construction lending agency for FRONT ! 1 e,1 6 2 3 8
the performance,of the work for which this permit is issued P L : l �+ I�
(Sec 3097 Civ C ) I SIDE + q t`� ty ° ` ti4^ `` s 03 3 0—8 8
Lender s Name }LDMA Ref #~ `+ a +d +
m P C Fee$ Permit Fee 7
Lender s Address
a I certify that I have read this application and state that the Issuance Fee 5� kLD P/C
#
above information is correct I agree to comply with all CountyInvestigation Fee 7
0 ordinances nd Stote jaws relating to building construction Totol Fee 2—,, LDMA Perm #
R and here authorize repres tatrves of this County to enter
upon ih mentioned ro artyf inspection purposes Y�ly t F ei a 1 - S 1
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of AlUont or Agen Date