HomeMy Public PortalAbout9968 BROADWAY_Building__ WORKERS' COMPENSATION DECLARATION
Insure, affirm that haver ce' C too tion Ins to self APPLICATION FOWBUILDING PERMIT
insure, or a certificate of Workers' Compensation Insurance,
of a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
P
BUILDING C/f_C7 -
Certified copy is hereby furnished. /FO�7R APPLICANT TO FILL IN ADDRESS / l(�r3 road
Certified copy is filed with the county building inspec- BUILDING
�(�/G G` 1 Cf(,f.C✓'✓'Lt
tion department,
I CITY' Q ' ZIP / ��� LOCALITY
Date IF
Applicant NO. OF BLDG$. NEAREST '
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. (�(�
COMPENSATION INSURANCE 11 ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT N MAP BOOK PAGE PARCEL
hundred dollars ($100) or less.) TEL' USE ZONE MAP
OWNER Lre% O e NO. NO.
I certify that in the performance of the work for which this r'- SPECIAL >
permit is issued, I shall not employ any person in any manner ADDRESS q G Q CONDITIONS O'
so as to become subject to the Workers'Compensation Laws. y, f/O O
CIZYTY eA'J ZIP O
Dote Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY K
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CO (O(t
ZONE
Exemption, you should become subject to the Workers' - w
Compensation provisions of the Labor Code, you must forth- ADDRESS •OC1 �..,1 lnt �✓ l<_ a
with comply with such provisions or this permit shall be TELp�f' I��T qQQ STATISTICAL CLASSIFICATION APT. CONDO. N
deemed revoked. CONTRACTO G NO.a2_` Z
LICENSED CONTRACTORS DECLARATION /� LIC. / CLASS NO. DWELL UNITS
—
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS`�g1d ca NO. 584' b )-
/CIM /1-1 /I LIC. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business (� 3 VALIDATION
and Professions Code,and my license is in full force and effect. SE FT O.OF NO. OF CLASS CHECK 8K. PG.
License Number Lic. Class SIZE STORIES FAMILIES ONE
((`` VALUATION b�
Contractor Date DESCRIPTION OF WORK .ear O'{' NEW ❑ $ T _
pn ��
I am exempt under Sec. 'L P'�• INLA`I Y�.° ALTER
❑
B.BP.C. for this reason 5LID ifr. S�LVS' c r "i
REPAIR ❑ $ ;) ( - --
Date: USE OF U
EXISTING BLDG. DEMOL ❑ i,. ""? -
Signature APPLICANT - TEL FINAL � _ [14
'•�'- ':'t'•"•ss�+^'� ,t
OWNER-BUILDER DECLARATION (PRINT) NO. DATE -n t'4"
I hereby affirm that I am exempt from the Contractor's License - 9 f?
Low for the following reason (Section 7031.5, Business and ADDRESS FINAL t' '
professions Code): PRESENT BY
BUILDING
I, as owner of the property, or my employees with ADDRESS i;
wages as their sole compensation,will do the work and - '"�+
the structure is not intended orff
oered for sale(Section LOCALITY //�^ "� .
7044, Business and Professions Code.) - MOVING TEL.... D T
CONTRACTOR NO.
co I
'
I,as owner of the property, exclusively contracting
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code.) _
CONSTRUCTION LENDING AGENCY REQSETT BACK YARD HWY TOTALpROP ALWEFROM EXIST.
I}!}!]I.–s;tilJ' �':'1 1�><
I hereby affirm that there is a construction lending agency for FRONT :c
the performance of the work for which this permit is issued P.L. _ (`ry'i j«:
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name
_ LOMA Ref. N
Permit fee ,
3 Lender's Address (-
I certify that I have read this application and state that the Issuance Fee LDMA P/C N
Ig above information is correct. I agree to comply with all County Investigation Fee oZ VOL•S
R ordinances and State laws relating to building construction, Total Fee / LDMA Perm. p
and hereby authorize rep se totives of this County to enter
upon the ove-menti ed perry for inspect u Pas S.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or nt D e _
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