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WORKERS' COMPENSATION DECLARATION '• �'
"
I hereby affirm that I have a certificate of.consent to self
insure, or a certificate of Workers' Compensation Insurance, . PLICATION FOR BUILDING PERMIT'
or a certified copy the' of (Sec. 3800, La C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy N0. ompany _ _.._.
Certified copy is hereby furnish d. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Certified copy is filed with the county buildirig inspec- BUILDING
tion department. ADDRESS
Date 1.1024. Applicant ~— CITY - -ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' O. 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
TEL.
.hundred dollars ($100)or less.) t TRACT BLOCK LOT. MAP BOOK PAGE PARCEL
_ USE ZONE MAP
E,- -OWNER-.
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner 1 SPECIAL - 0
so as to become subject'to the Workers'Compensation Laws. ADDRESS--
CITY'
DDRESS-CITY• _ ZIP �{
Date Applicant ' ARCHITECT OR TEL. O
NOTICE TO APPLICANT: If, after m _making�ikis Certificate of ENGINEER NO. DISTRICT- - GROUP TYPE FIRE- PR SED BY
Exemption, you should become subject to the Workers' ,+ �V� CONST. ZONE
Compensation'provisions of•the Labor Code, you must forth- ADDRESS o� Jt(f� ) tV/ 9L
with comply- with such provisions or this.permit shall be V)
deemed revoked..
TEL STATISTICAL CLASSIFICATION APT. C DO:' Z
CONTRACT NO
LICENSED CONTRACTORS DECLARATION - LIC. CLASS NO. 2 DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (p
(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 VALIDATION
SFT. . OF OF CHECK
License Number (P/^�—Lic.Class � SIZE
STOE STORIE FAFA MILIES ONE
VALUATION
� DESCRIPTION OF WORK NEW to
Contractor � ate: ADD ❑ $ Vv
❑ I am exempt under Sec. ,
ALTER
B.BP.C. for-this reason EPAIR $
Date: USE OF
Date: ❑
EXISTING BLDG. -
Signature - APPLICANT TEL. FINAL
OWNER-BUILDER DECLARATION PRINT) NO. DATE -
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
Professions Code): "' PRESENT . BY 1
BUILDING
❑ I, as owner of the property, or my employees with ADDRESS_ 4 9S 1'A-
wages as their sole compensation,will do the work and ,
the structure is not intended or offered for sole'(Section LOCALITY
o o, 0 0 0
7044, Business and Professions Code). MOVING - - TEL.
CONTRACTOR NO.
❑ I, as owner of the property, am exclusively contracting Q 5 0
with licensed contractors'to construct the'project (Sec- ADDRESS
tion 7044, Business and Professions Code). •e a a 4 Q 550:11
REQUIRED YARD. HWY TOTAL SETBACK FROM XI
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH'
I hereby affirm that there is a construction lending agency for FRONT Q ];Q 2—86
the performance of the work for which this permit is issued P.L.. '
(Sec. 3097, Civ. C.). SIDE
m P.L. _
Lender's Name
g LDMA Ref. #
P.C. Fee$ Permit Fee. 6 �/v '
Lender's Address
certify-that I have read this application and-state-that the - Issuance Fee- O t J:V kLDA P/C#
Q above information is correct. I agree to comply with all County Investigation Fee -
o ordinances and State laws relating,to.building construction,
u and hereb authorize representatives of this County to enter - Total Fee (/ LDMA'Perm. #
upon the ve-mentioned property for inspection purposes.
/!,1�/A.. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Acfent Date' - _ _ Q i