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'• WORKERSCOMPENSATION DECLARATION
I hereby affirm that I havm a certificate of consent To self
insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800, "Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company i
BUILDING
❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS cq
El Certified copy is filed with the county building inspec- BUILDING /_X�P/ '}D
tion department. ADDRESS (f? !/
I C T—�
CITY / ZIP LOCALITY
Date Applicant O. OF BLDGS.
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST.NEAREST
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) u�� C.��f� ,l T L �� USE ZONE MAP
OWNER C. �! /�,l
certify that in'the performance of the work for which this SPE
permit is issued, I shall not employ any person in any manner ADDRESS _ JV,01Cor"'T CONDITIONS n
so as to become subject to the Workers'Compensation Laws. �y O
CITY ZIP U
Date Applicant ARCHITECT OR TEL. DISTRICT CjROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO.
Exemption, you should become subject to the Workers' it I f CONST. E U
Compensation provisions of the-Labor Code; you must forth- ADDRESS
with comply with such provisions or this STATISTICAL CLASSIFICATION �, AP CONDO.
N
p y p permit shall be TEL. Z
deemed revoked. CONTRACTOR NO.
to
LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO.
(commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION
SQ. FT. NO. OF NO. OF CHECK
License Number Lic. Class SIZE I STORIES FAMILIES ONE
VALUATION
Contractor Date DESCRIPTION OF WORK NEW ❑
$
/O oDO
ElI am exempt under Sec. L 1r, O, El ,
ALTER ;
B.BP.C. for this reason REPAIR ❑ $
Dater USE OF
EXISTING BLDG. DEMOL ❑
Signature APPLICANT TEL. FINAL /1
OWNER-BUILDER DECLARATION. (PRINT) NO. U
I hereby affirm that I am exempt from the Contractor's License DATE
Law for the following reason (Section 7031.5; Business and ADDRESS FINAL 1
FPro essions Code): PRESENT By ttit i oY
I, as owner of the ro ert or m employees with BUILDING
/ P P Y� YADDRESS -t^��
wages as their sole compensation,will do the work and ► X307 1�4•'-'''
the structure is not intended or offered for sale(Section LOCALITY 1
7044, Business and Professions Code.) MOVING TEL. ITEMS
CONTRACTOR NO.
❑ I, as owner of the property, am exclusively contracting (i�'i�L }'ss. m
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) :}{EC
REQUIRED TOTAL SETBACK FROM EXIST. L���t,�
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH (;Fltlt!(7 .s]J
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. 0.000-0001 12! 5/89
Lender's Name. t� C[��{{
LDMA Ref. # 129 1 PM 1 °L
P.C. Fee $ Permit Fee
a Lender's Address '
a 1 certify that I have read this application and state that the Issuance Fee ` "v LDMA P/C#
above information is correct. I agree to comply with all County Investigation Fee
8 ordinances and State laws relating to building construction, Total Fee (� r0 LDMA Perm. #
and hereby authorize representatives of this County to enter
W up s above-menu d properf for ' spection put oses
•o lZ 9 SEE-REVERSE FOR EXPLANATORY LANGUAGE
Signature f Applicant or nt ate /