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HomeMy Public PortalAbout9156 EMPEROR AVE_Building__ WORKERS' COMPENSATION DECLARATION hereby,affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers'Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES - BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR,APPLICANT TO FILL IN ADDRESS OCertified copy is filed with the county building inspec- BUILDING �— tion department. ADDRESS �IZr ' J LOCALITY ` t NEAREST 11/7 Date Applicant CITY X11^ 1" _ ZIP CROSSST. CERTIFICATE OF EXEMPTION FROM WORKERS'' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONA FMAPhundred dollars ($100)or.less.) TRACT BLOCK LOT NO. _ / .TEL. / a ECIALI certify that in.the performance of the work for which this OWNER ��1 ��. NO.� j'7�F� �U NDITIONS permit is issued, I shall not employ an person in an manner P DISTRICT GROUP TYPE FIRE PROCESSED BY P P Y y P Y /� CONST. ZONE so as to become subject to the Workers'Compensation Laws. ADDRESS 1 f 1 1',, f 1 P CITY %' �/ ZIP 7� f STATISTICAL CLASSIFICATION J APT. CONDO. Date Applicant U ARCHITECT OR TEL. r NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER ((��+ •t �� NO. ~7 CLASS NO. / DWELL. UNITS 0. Exemption, you should become subject to the Workers' 114 Compensation provisions of the Labor Code, you must forth- ADDRESS ,L ("1' J`` /> SEWER MA with comply with such provisions or this permit shall be TEL. deemed revoked. CONTRACTOR NO. VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. /, n Professions Code, and my license is in full force and effect. CITY CLASS $ SQ. FT A RR.+ NO. OF NO. OF CHECK License Number Lic.Class SIZE �V. STORIES �. FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW • I am exempt from the licensing requirements as I am a ADD licensed architect or a registered professional engineer ALTER FINAL acting in my professional capacity (Section 7051, ❑ DATE REPAIR Business and Professions Code). USE OF' FINAL EXISTING BLDG. DEMOL' By Lic. or Reg. No. Date` APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License (c2 Law for the following reason (Section 7031.5, Business and ADDRESS . Professions Code): PRESENT BUILDING Z U F I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY � -7044, Business and Professions Code). MOVING TEL. EI, 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). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there,is a construction lending agency for FRONT vv the performance of the work for which this permit is issued P.I. (Sec. 3097, Civ: C.). SIDE P.I. Lender's Name O Lender's Address P.C. Fee$ a Q Permit Fee w I certify that I have read this application and state that the Issuance Fee �l above information is correct. 1 agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee ' T and hereby authorize,representatives of this County to enter + aupon the above-mentioned property for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dote ©s