HomeMy Public PortalAbout10365 KEY WEST ST_Building__ WORKERS' COMPENSATION DECLARATION
nt to
insure, or afirm certif carte of Worke s' Comtpensat on Insuran elf 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 BUILDING
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING ;
tion department. ADDRESS'
Date Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. y'
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
TEL. USE ZONE MAP
I certify that in the performance of the work for which this OWNER NO. NO /r" Il
permit is issued, I shall not employ any person in any manner SPECIAL 0
so as to become subject to the Workers'Compensation Laws, ADDRESS CONDITIONS
LU
CITY ZIP 'J
Date Applicant LL
TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP CONST. ZONE r l
ENGINEER NO.
Exemption, you should become subject to the Workers' Q
Compensation provisions of the Labor Code, you must forth- ADDRESS °" - p:
with comply with such provisions or this permit shall be
TEL. STATISTICAL CLASSIFICATION APT CONDO. O
deemed revoked. CONTRACTOR NO. d
LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS W
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 LIC. SEWER MAP
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 ISTORIES FAMILIES ONE
❑ VALUATION
Contractor Date DESCRIPTION OF WORK NEW
ADD ;
I ❑ I am exempt under Sec. ❑ ` 1 r A
ALTER
B.&P.C. for this reason REPAIR ❑ $ ?' s ♦ ♦ • "`?
Date: USE OF DEMOL ❑
'I EXISTING BLDG.
Signature APPLICANT TEL FINAL
OWNER-BUILDER DECLARATION (PRINT) NO. DATE • ♦ r
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL 'f;L'
Professions Code): PRESENT BY
❑ BUILDING
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
❑ 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). a a s •r
CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM EXIST,
SET BACK 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
o LDMA Ref. #
CO
Lender's Address P.C. Fee$ ",� (� Permit Fee
I certify that I have read this application and state that thef z f 1 Issuance Fee LOD MA P/C#
above information is correct. I agree to comply with all County Investigation Fee ry
ordinances and State laws relating to building construction, Total Fee LDMA Perm. #
u and hereby authorize representatives of this County to enter
( m upon the above-mentioned property for inspection purposes.
Q SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Applicant or Agent Date F