HomeMy WebLinkAbout0013A (7)WORKERS' COMPENSATION DECLARATION
e of
nt to self
paifcertificate
e that I have a of care of Workers' iComtpensal oneInsurance,
or o cerlifisd copy thereof (Sec. 3800, Lab. C.)
Policy No, Company
Certified copy Is hereby furnished.
Certified copy is filed with the county building inspec-
uon deportment.
aIs' _ Applicant
\ CERTIFICATE Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one
hundred dollars (S100) or less.)
I certify that In the performance of the work for which this
permit is issued, I shall not employ any person In any manner
so as to become subject to th, Workers' Compensation Laws,
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply. with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chaptsr 9
(commencing with Section 7000),of Division 3 of the Business and
Professions Code, and my license is in full force and effect,
License Number tic. Clau —
Conlroclor, Date .-------��
1 am exempt under Soc.
54P.C. for this reason
Date: -
Signature
OWNER -GUILDER DECORATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professiont Code):
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not Intended or offered for sale (Section
7044, Business and Professions Code).
1, Ott owner of the properly, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 70", Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that Wsfi Is a construction lending agency for
the performance of the work for which this permit Is issued
(Sec. 3097, Civ. C. ),
Lender's Name
Lender's Address
I certify that I have read this application and slate that the
above information Is correct. I agree to comply with all County
ordinances and $tote laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the obove-mentioned property for Inspection purposes,
lint... eA Applicont or Agent Date
APPLICATION FOR
BUILDING 1
COUNTY OF LOS ANGELES
B4)ILDING AND SAFETY
BUILDING s o r/ qlc ZL:i
FOR APPLICANT TO FILL IN
ADDRESS J
BUILDING ®1 5 S e f► GD, C i e
ADDRESS i�
ttN1. � � V ZIP J � � � �
LOCALITY %"
CITV 1
NO OF BLDG$.
s e NOW ON LOT
NEAREST
CROSS ST.
SIZE OF LOT
d aBLO ' 1 CK LOT NO.
ASSESSOR V
MAP BO PAGE PARCEI `'
TRACT TEL
�J � ,p}•}� O. I . �,�
_3 YTMN
USE ZO E
T2 —I� D �
O.
OWNER
- ; -? s `r
s4
SPECIAL
CONDITIONS
U
ADDRESS
Qrok �� ZIP ci 1 p "/-s /N
FIRE D BY
N
CITY TEL.'%) ";i °
ARCHITE OR s CtM r NO,
DISTRICT GROUP TYPE
CONSt
S �+� Qvl s
I to K--3
APT, CON00.
4
ADDRESS
STATISTICAL CLASSIFICATION
Z
�'
NO. L�L DWELL. UNITS
r
CONTRACTOR
LIC,
CLASS ------
ADDRESS NO,
tic,
SEWER MAP
p VALIDATfON
L G
CITY CLASS
SQ. FT. �r NO. NO. OF ' CONE
O STORIES F I i 1
BK. PG.4 q
f N � O O 1.3 A
SIZE
NEW
ALUATION /
�....23
ADD Q
ALTER1,3221
B
REPAIR ❑
( S
'
3 � ► 1• 2 ?')USE
OF DEMOL 0
EXI TING BLDG, TEL^
•
FINAL Q 7. 2 1 —
-
APPLICANT I-je NO.
av
DATE
PRINT
II .,�/J
ADDRESSt�.S CI' lA""+ c�'' 4,18Nim `
�� AL
BUILDING
ADDRESS
r K I cxyc Co1�A�I 1 C�
LOCALITY
top d
TEL.
h
MOVING ern
YARD I HWY
s ( Permit Fee
Issuance Fee IDP/C N
MA
on fee LOMA Perm, N
Total Foe
t- h
SIV "VNNSN VON IXPLANATONY AANl3UAON