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HomeMy Public PortalAbout9229 PENTLAND ST_Building__ WORKERS'COMPENSATION DECLARATION (� 1 hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' CompensationionInsurance, or a certified copy thereof (Sec. 3800, Lob. C.) r . !`[/.:v l� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company C Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS © Certified copy is filed with the county building inspec- BUILDING tion department. ff ADDRESS Date �% / ' `v Applicant 4 �.' ?-J CITY Lt lC ! ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' O.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. 14 (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 } - OWNER - J USE ZONE MAP O I certify that in the performance of the work for which this 7, NO. NO U permit is issued, I shall not employ any person in any manner / 'l; t SPECIAL W so as to become subject to the Workers Compensation Laws. ADDRESS _ - CONDITIONS LL Dote Applicant CITY - c- ZIP ARCHITECT OR TEL. } NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY Exemption, you should. become subject to the Workers c CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS / (1 t - O with comply with such provisions or this permit shall be d deemed revoked. TEL. STATISTICAL CLASSIF TIOy/ l APT. W. ?3. CONTRACTOR �-.:�.. l � :. .NO. u/y LICENSED CONTRACTORS DECLARATION i LIC C1A55 NO. DWELL. UNITS - ? H I hereby affirm that I am licensed under provisions of Chapter'? ADDRESS /: NO, SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC Professions Code, and my license is in full force and effect. CITY r lGCi CLASS l BK - PG )' VALIDATION / SO. FT. NO.OF ( NO.OF CHECK License Number / Lia Closs L SIZE STORIES FAMILIES ONE VALUATION /, I ' DESCRIPTION OF WORK NEW Cl Contractor ,J - Date ' $ ADD , I am exempt under Sec. ALTER B.BP.C. for this reason ! - REPAIR $ USE OF Date: EXISTING BLDG. DEMO[ � n Signature APPLICANT TEL - /% PRINT . NO. DATEFINALt OWNER-BUILDER DECLARATION DATE • • • • • I I hereby affirm that I am exempt from the Contractor's License f. Law for the following reason (Section 7031.5, Business and ADDRESS GJ- 'r^� FINAL Professions Code): By ❑ BUILDING C 'T I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and L the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. Oil. DI, 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 SETT BACK YARD HWY TOTAL PROP.AL LICK NE WIDTH I hereby affirm that there is a construction lending agency for —FRONT the'i performance of the work for which this permit is issued P.I. (Sec. 3097, Civ. C.). SIDE P.I. Lar'der's Nome LDMA Ref. R '$ d P.C. Fee$ Permit Fee >>- Ladder's Address 7E I certify that I have read this application and state that the Issuance Fee LDMA P/C N a4bve information is correct. I agree to comply with all County Investigation Fee _odinonces and State lows relating to building construction, Total Fee LDMA Perm. IF u and hereby authorize representatives of this County I enter upon the above;menhoned property for inspection purposes. r 6 �l_ //j-- -4 SEE REVERSE FOR EXPLANATORY LANGUAGE �L / // ILCSignature of Applicant or Agent Date