HomeMy WebLinkAbout4330WORKERS' COMPENSATION DECILARATION
c�ffitrn thcat ; haver f nt to se€f
lboote
'F R
ureE
ton ruivronce,
Workers'
insure, or certificate vorlcer�' i er
ns tin
AP��������N
', ��'��ru ri ERI
or o certified Copy thereof _ �,
-
COUNTY Of Los ANGELES
BUIL01140 AND SAFETY
Certified copy i hereby f=. r�#�ecli
7 PPN 1ADDRESS
B i I� ,
ified copy is filed with thia county burldirv. m pec-
tion d��e
BUILDING
Ai RESS
1 +
Cao, � licont4FROf�
W
CITY
Zip
LOCALITYERTIF�TE
F EMT
N
WEARE T
COMPENSATION lNS RAN E
SIZE OF L T
wow, ON
Sr.
(This section -,need nor be completed if the permit is for one
ASSESSOR
hundred dollars [ i ; or less
TRAM BLOCK
LST tv�3MAP
BOOK PAGE
PARCEL
I certrfy that in the performance of the work for which this
CO ME
' SEL
_
NE MAP
CSE L r
u s £
per€nit Is issued, I sh6ll not employ any person tri ony manner
� ``§
so as to become sud*On
,ect to e oekers n
Co pescitkin tows,
�
NDMOP-�
.
0ZIP
pIlcnt '
�, af€er making" this Certificate of
*���become
A�4iF; R C}R
I��
TEL,
�_
S E B 0I
�TRt� UP TY E FIRE
subject �e� Workers
Com_ ZO
�
raper tion provisions,of the Labor Code= you must forth-
ADDRESSwi_
with coarply with such provisions or this gait shelf be_
9
deemed revoke&TEL
CONTRACTOR
0 _
SrATISTICAL CLASStftCATM-4
APT
LICENSED CONTRACTORS DECLARATION-
CLASS NO. DWELL UNITS
I hereby affirm that I am licences cinder provisions of Chapter9
ADDRESS
(commen in with Section � of Division S of the Business and
L
SEWER A&AP
0
Prt�fc€ons yen ,'� effect
.�
CLAS
Sc _ N OF
SIZ STORIE
Nom, OF CHECK
—���..
��
i � Num erL Iris
ILI S
DESCRIPTION OF WOR
NEW
�
o` irtscta
ADD
ALTER.
r.
B. P. . for this reason
REPAIR
_
USE OF
-Date:
EXISTING BLDG.
DEMOML
Si hatur �
OWNER -BUILDER DECLARATION �
APPLICANT
tlty I
TEL .
NO �
FINAL � a
� DAA
I,*ereby aurae that I am exe pt from the Contractor's License
ADDRESS� � �
�s. 1 4
Love for the following reason (Section 7031.5,i.S, Business and
RN
-Professions Code):
By
[, as owner of the propeme, or my employees with
BUILDING
ADOMS
Wages as'their sole cornpe scitaon, will do the work and
the structure is not intended or offered for sisle (Mian
LocalTy
7044, Businessord Professions Code)
�-
TEL,
OF
I, a owner of the property_ am exclusively contracting
CONTRACTOR
NO.
f
with licensed contractors to construct the project (Sec-
-titan
tion , Business and Professions Code).
ADDRFSS
CONSTRUCTION LENDINGAGENCY N LENDINC NCY
REQIRE
BAS YAR t WY
TOTAL I
LINE T
I hereby affirm that there is a construction lending agency for
FRONT
the perfornionce of the work for which this permit is issued
L,
(Sec, ..SIDE_
_
m
a
Leveler's Nan
_.
LLt1A Ref.
E
Lender's Address
P.C. Fee
Permit Fes:
I certify that t have read this application o€ad state tot the
dunce Fee
P/C
above info tion i