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HomeMy Public PortalAbout9609 BROADWAY_Building__ WORKERS' COMPENSATION DECLARATION Y'k hereaffirm that hovecertificate of consent to self APPLICATION FOR BUILDING PERMIT insure,, or o certificate of Workers' Compensation Insurance, or a#ertified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company F-1Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING f-1Certified ,� Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS his n Date Applicant CITY G ZIP Q LOCALITY Y pis L�`l7 CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NO.OF SLIDNOW ON LOT CROSS ST. NEAREST COMPENSATION INSURANCE .� (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR hundred dollars (b100)or less.) MAP BOOK PAGE PARCEL TEL. / USE ZONE MAP I certify that in the performance of the work for which this OWNER NO. L NO. permit is issued, I shall not employ any person in any manner � ''r `� SPECIAL pDDRE55t so as to become subject to the Workers'Compensation Laws. CONDITIONS 0• CITY ZIP C.1 Dale e .-2- —..Applicant �p /atey ! ' ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after makingth is Certificate of DISTRICT GROUP TYPE FIRE PROCESSED BY 0 Exemption, you should become subject to the Workers' ENGINEER NO. CONST. , / ZONE 1-- Compensation provisions of the Labor Code, you must forth- ADDRESS 151W I R-31V W with comply with such provisions or this permit shall be A deemed revoked. STATISTICAL CLASSIFI ATION APT. C DO. Tn CONTRACTOR NO. Z 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 and tic, SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK PGVALIDATION SO. FT,i..,i.L� NO.OF NO.OF CHECK License Number Lic.Class SIZE S9p TORIES © FAMILIES ONE ❑ VALUATION Contractor Date DESCRIPTION OFF WORK NEW S �t AD TIL'N ® I am exempt under Sec. ADD ❑ B.BP.C. for this reason 7L Lq1i ALTER lop REPAIR ❑ .s Da B' USE OF EXISTING BLDG. z Z! DEMOL ❑ s'onoNre APPLICANT - ` ;20 5 9.2 A y/ OR-BUIP -DECLARATION PRINT _ FINAL • �/ I hereby affirm that I am exempt from the Contractor's License �C DATE # e e • • •�� Law for the following reason (Section 7031.5, Business and ADDRESS /�'aJ - 28200 r�8.L Q Q Professions Code): PRESENT ❑ BUILDING I, as owner of the properly, or my employees with ADDRESS • -2 82 Q,Q v wages as their sole compensation,will do the work and �� � G,� , the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. tc9.02-88 ® 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 REQUIRED AC EK YARD HWY I PROP. LINE WIDTH 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 $ LDMA Ref. k Lenders Address P.C. Fee$ Permit Fee ' I certify that I have read this application and state that the Issuance Fee S LDMA P/C If a above information is correct. I agree to comply with all County Investigation Fea (, q ordinances and State laws relating to building construction, Total Fee Q t0 6 1 LDMA Perm. If R and are r uthoriz9 representatives of this County to enter upon I a ov - 6 i d ty for inspection purposes, 2L¢O SEE REVERSE FOR EXPLANATORY LANGUAGE Signature .Applicant or Ag Date