HomeMy Public PortalAbout9015 EMPEROR AVE_Building__ WORKERS'COMPENSATION DECLARATION
`T insureboraafcertif cafirm tharte of Workers' Comtpensat on eInsuran nt to e, APPLICATION FOR BUILDING PERMIT
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 ADDRESS
BUILDING
❑ Certified copy is filed with the county building inspec- BUILDING D1� Em ,e 0-t
Tion department. ADDRESS 1
Dateyy;Lo'bg Applicant CITY "'e "e C ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM ORKERS' 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. MPA
AP BOOK GE PARCEL'
-TEL. USE ZQNE 1` / MAP
I certify that in the performance of the work'for which this OWNER � (� d NO. 1p/`(J NO.
permit is issued, I shall not employ any person in any manner SPECIAL
ADDRESS CONDITIONS
- so as to become subject to the Workers'Compensation Laws. U
CITY ZIP
Date Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE FIRE PROCESSED BY
GINEER NO.
Exemption, you should become subject to the Workers' EN -. CONST. t ZONE V
Compensation provisions of the Labor Code, you must forth- ADDRESS v
with comply with such provisions or this permit shall be sp TEL � �'^�
deemed revoked. CONTRACTO �l V NO. I I STATISTICAL CLASSIFICATION APT. NDO. z
R
LICENSED CONTRACTORS DECLARATION n e �� LIC. ),14r)146CLASS NO. DWELL. UNITS
-
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1�1�/ NO. SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and LIC.
Professions Code, and m license is in full force and effect. CITY �Ukc4l L -e . CLASS 416 BK PG VALIDATION
/ � 2,4f� �Z (
SQ. FT. SNO.TO IE NO. OF CHECK
License Num er f..� �y Lic.Class� SIZE STORIES FAMILIES ONE .
O L i -if Pt t NEW ❑ VALUATION
Contractor Date "^' DESCRIPTION OF WORK $ `6"n
❑ I am exempt under Sec. l �p�`(�L AADDLTER O VV`'��J , �0.9.5.6 A
�r� �� Uhf s # . . . . a:1
8.8P.C. for this reason ^ REPAIR
Date: USE OF / DEMO! ❑ ) ° 5 O O
EXISTING BLDG. W Z
Signature APPLICANT TEL. /_ FINAL ° ® 1 5 3 0 Q�V
OWNER-BUILDER DECLARATION PRINT L C(}Wl NO. �1���s DAT � i( Q Z,Q`'8 S
I hereby affirm that I am exempt from the Contractor's License i / , lei f
Law for the following reason (Section 7031.5, Business and ADDRESS SL ` FINAL
Professions Code): PRESENT By (r )
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will dothe work andthe structure is not intended or offered for sale(Section LOCALITY Vt,-q
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).
M EXIST.
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAPROP. ACK LIINEF 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 (JJ LDMA Ref. #
m
P.C. Fee$ Permit Fee c� V
Lender's Address f /�
1 certify that I have read this application and-state that the Issuance Fee l OC Ci LDMA P/C#
g above information is correct. I agree to comply with all County Investigation Fee
0 ordinances and State laws relating to building construction, Total Fee .(J LDMA Perm. N
and hereby Lve-mentioned
orize representatives of this County to enter
upon th a propert for inspection purposes.
bp
'In 10-,a
� SEE REVERSE FOR EXPLANATORY LANGUAGE
Si-9n;turgfof Applicant or Agent Dote