HomeMy Public PortalAbout9557BISBY ST_Building (6) WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
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
ADDRESS
Certified copy is filed with the county building inspec- BUILDING
tion department. �.r' / ADDRESS
Date Applicant r'`rl CITY ZIP 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 ASSESSOR >;hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL Ll:
TEL. USE ZONE MAP O
I certify that in the performance of the work for which this OWNER NO. NO. 0
permit is issued, I shall not employ any person in any manner SPECIAL W
so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS J
L%
CITY ZIP >„
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP I TYPE FIRE PROCESSED BY
ENGINEER NO. CONST ZONE
Exemption, you should become subject to the Workers' LY_
Compensation provisions of the Labor Code, you must forth- ADDRESS 0
with comply with such provisions or this permit shall be CL
TEL. STATISTICAL CLASSIFICATION APT. CONDO.
deemed revoked. CONTRACTOR NO.
LU
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS F—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business and ; LIC SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATON
SQ. FT. NO.OF NO.OF CHECK a s a a
License Number Lic.Class SIZE STORIES FAMILIES ONE
VALUATION ; .e 4 h
Contractor Date DESCRIPTION OF WORK NEW ❑ ; ,e
j
t % j ❑ ,
am exempt under Sec. ADD ❑
ALTER
B.BP.C. for this reason REPAIR ❑ $
Date: USE OF MOL
EXISTING BLDG. DEA
A011
Signature APPLICANT FINAL -
OWNER-BUILDER DECLARATION PRINT NO. DATE
I hereby affirm that I am exempt from the Contractor's License I a
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): PRESENT BY a r
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
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- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP.pLINE WIDTCK-FRIPM H
I hereby affirm that there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name TDMA Ref. ti
P.C. Fee$
Permit Fee ,
Lender's Address
I certify that I have read this application and state that theIssuance Fee LDMA P/C M
o above information is correct. I agree to comply with all County Investigation Fee
°o ordinances and State laws relating to building construction, Total Fee LDMA Perm. 0
and hereby,authorize representatives of this County to enter
$ upon th ove-die ton property for inspection purposes.
Q,r .�-
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date