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<< WORKERS COMPENSATION DECLARATION /
_ t I'here y affirm that I have a cert of consent self APPLICATION FOR BUILDING PERMIT
insure or a certificate of Workers Comompepenstion Insurance
e or
a certified copy thereof (Sec 3800 Lab C ) COUNTY OF LOS ANGELES BUILDING-AND SAFETY
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec BUILDING - r'J
tion department ADDRESS LOCALITY ('
_ NEAREST
Date Applicant CITY ZIP CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS O OF BLDGS ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one //� (� USE ZONE MAP
hundred dollars ($100)or less ) TRACT lD ✓ BLOCK LOT NO / NO Q (% >.
TEL SPECIAL d
(,certify that in the performance of the work for which this OWNER r NO r CONDITIONS Q
permit is issued I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROC SSED BY V
so as to become subject to the Workers Compensation Laws ADDRESS —� CONST ZONE
O y
J 1!// 3 O
Date Applicant CITY ZIP 7 STATISTICAL CLASSIFICATION PT` CONDO V
NOTICE TO`APPLICANT If after making this Certificate of ARCHITECT OR - ~TEL 6L1
Exemption you should become subject to the Workers ENGINEER NO
CLASS NO DWELL UNITS
Compensation provisions of the Labor Code you must forth ADDRESS SEWER MAP Z
with comply with such provisions or this permit shall be TEL
�f
deemed revoked CONTRACTOR NO ` BK [i PG / VALIDATION
LICENSED CONTRACTORS DECLARATION LIC
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION
(commencing with Section 7000)of Division 3 of the Business and LIC
Professions Code and my license is in full force and effect CITY CLASS 0'` p"�
SQ FT NO OF NO OF CHECK
License Number Lic Class SIZE STORIES FAMILIES ONE \
Contractor Date DESCRIPTION OF WORK NEW ❑ _
❑ ADD ❑
I am exempt from the licensing requirements as I am a "
licensed architect or a registered professional engineer ALTER FINAL
DATE
acting in my professional capacity (Section 7051 %EPAIR ❑
Business and Professions Code) USE OF DEMOL ❑ FINAL
EXISTING BLDG i BY
Lic or Reg No Date APPLICANT TEL
OWNER BUILDER DECLARATION PRINT NO
I hereby affirm that I am exempt from the Contractor s License
Law for The following reason (Section 7031 5 Business and ADDRESS
Professions Code) PRESENT
BUILDING
I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and LOCALITY z 3 4 2'J A
the structure is not intended or offered for sale(Section
7044 Business and Professions Code) MOVING TEL
1 as owner of the property am exclusively contracting CONTRACTOR NO # e o o e o
with licensed contractors to construct the project (Sec ADDRESS 2 ° - 2500
tion 7044 Business and Professions Code)
REQUIRED TOTAL SETBACK FROM EXIST 2 5 G 0
CONSTRUCTION LENDING AGENCY ( SET BACK YARD HWY PROP LINE WIDTH �_s . o e o
I hereby affirm that there is a construction lendtng agency for FRONT //�� - /
the performance of the work for which this permit is issued P L V � 121 ,5-80
(Sec 3097 Civ C ) SIDE "
PL '
Lender s Name
P C Fee$ Permit Fee
� Lender s Address
w I certify that I have read this application and state that the Issuance Fee
° above information is correct I agree to comply with all County Investigation Fee
0 ordinances and State jaws relating to building construction — Total Fee 4
and hereby authorize representatives of this County to enter
a upon the above mentioned property for inspection purposes
�\�,�, � � �ej a�,C � f Z_I�•�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa u�e of Applicant or Agent Date
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