HomeMy WebLinkAbout1759A - WORKERS' CDMPENSATION 7ECLARATI�N -
� '." hereby affirm that I have a cerlificaie of consent to self �' � � � � 4�
i�sure, or o certificate o# Workers' Compensation Insurance, �
�;�a certified copy fhere { . 38D0, L b. y
Policy Nn����`'�� ��.��any ��.��'�� �'�' � COUP�ITY OF LO5 AfVGELES BLIILDING /ANU $AFEI'Y
;I� Certified copy is hereby#urnis�ed. � FOR APPLICANT TO F[LL IN qao��� ��� � ��� (�i
❑ Cerfified copy is filed with the county building inspec- 81311DING
�tian deparlmeRt, ���� � �� � At�o�tESs "�. � �f�j ��, ,
6
pate ° � Appiicant ��"�``° CITY �� � � �� ZIP LOCALITY a��}� (�..r"�
CER7IFICATE QF EXEMPTfQN FRQM WORKER ' Np, OF BtDGS. NEAREST � o°
r� I � COMPENSA�IOfV INSURAI+JCE SIZE OF LOT NOW OIV LOT CROSS ST. ��-.-��C'�.�.C�`�.�C:�, ���C�..`,��\:U5'D`
-ti.
{This etfion need nof be completed if ihe permit is for one TkACT BLpCK LOT NO. � ASSESSOR
hundrad doilars {$1d0)or less.) j MAP BOOK PAGE PARCf�
OWNER �'�f �""t� NO. USE ZOI+I� �� � j�
I certify that in the per#ormance of the wark for which this ��• d � f
perm€1 is issued, l shall not employ any person in any manner SPECiAL £-�;,,
so os to become subject to the Workers'Compensation Laws. ADdRESS �� � �� � � CONDITIONS r°-;
CITY Ck��t.��� �� ZIP �, �F�y
�ate � . Y . . APPlitanf I9. . ENG1NEERTOR ��� "� N� �� �t}�j t�ISTRICT GROUP CP�� fl��, PitOC�EDSY /^"S
NOTICE TQ APPLICANT: If, a#ter mokin this Certificate of r
Exem Fion, ou should become sub'ect 10 lhe Workers' p� ��� -� �
Compensation pro�isFons o#the Cabor Code, you mus!forth ADDRE55 � ,� < t� �,,, ���"' �� .�� !�` ��(,'�\���,_, ;��^:
with compfy wifh such provisions or tMis permit shall be ��i �� � TE�. STA7157lCAL CLASSIFICATION APT. CdN�O.
deemed revoked. CONT A To �` NO.
LfCENS£D CdiVTRACTORS�ECLARATION ���, ,,, � CLASS NO. �� DWELL. UNITS °`
I Frereby affirm that 1 am Ilcansed under provisions of Chapter 9 AOORESS '�„°�,� �� 'r',�`. NO. ���
(commencing with Section 7000)of bi�ision 3 of the 8usiness and uC. SEWER AAAP
Professions Code, and my license is in full force and effect. CITY � -��"i �. ���'°"` CLAss VqEfDATtOP!
�^- � Sq. FT. NO.Of NO. OF CHECK gK� �'' �- � �- c
License fJumber �� � Lie,r�lass � SIZE ST�RIES FAMILIES ONE �= � � '� �' <<�
�f��� (� t�s� �I��,�� VA�uAriar� , - �
` � NEW t`j, c ;. :: „ i? ,j
Canffaclor Dp1e - -- DESCRIPTION OF WpRK � � ❑ •
_--
- AbD § ��
❑I am e �t undar 5ec. � 't"�� � f�� � f � 1 �7 �I,<:� i� �
� AL7ER
� ��t� • r. '� ., , -i-
6.&P.C, for thls reason � REAAIR ❑ � � � I �- !� �:`.�-��, ��'.
� Dote: U5E OF pEMOL [� '� '
EXISTING SL�G, � (� �, r_ � `_� ._ _.
Signaiure APPLICANT � re�. �y F��y��
OWNER-BUILDER DECLARATION PRiNT �:�....�-.� �� CNO. � ` 1� pATE
I hereby a#firm that I am oxempt from tha Contractcr's License � $
law for the following reason (Sedion 7Q31.5, Business and ADDRE55 ���p�d
Fro€essions Codef: �y
� BUILOING
I, as awnar af the praperiy, or my employoas with qopRE55
wages as their sole cpmpensplion,wlll do ihe wark and
�he structure is not intanded or o#fered for sale(5eetion LOCAIITY
7Q44, Business and ProfessSans Codey, MOVING TEL
� I, as vwner o#the property, am exclusively confrpcting CONT{2ACTOR NO. :r' c' �� �� �::.' JL
w€th Iicensed contracrors to canstruet the projecf (5ec- .r�
tion 7flA4, Bus'sness and Professipns Code}. ADbRE55 ,�; � �:^ �- , , 'i
REQVIRED TpTAI SETBACK
CONSiR�JCTION LENDING AC�ENCY SET BACK YARO WWY pROP, LINE WIDTH ( e � �;;?,(; O
I hereby affirm that lhere is a cpnstruclian lending agency for FRONT
the performance of the work for which this permif is issued P.L. , ,^��, � �, ; ;
{5ec. 3097, Civ. C.). SIDE
Eander's Name P.l. � �) �� " ,�; <'%
�$�b �" IL»N4A Ref. 41
m P.C. fee$ � r, Permil Fee I _T��
Lender's Address
� I certify lhat 1 6�ave read ihis appiieaiian and state fhaF fhe Iswance fee �� ,��� LDhhA P/C#
� obove information is correct. 1 agree to comply wilh all Caunty Invasti ation Fee
0 ord€nances and ate laws relating to buikding construcfion, Total Fea� (� ��
� and heraby aut orize represenfoSi�es of this County to enier g �-`�' � � LDNLA Perm. if
� upon 1he a6ov -menlione p op rt for inspection purposes.
4 a � ` S£E REVERSE POR£XPLRI+IATORY LANGUAGE
A
Signature of Applicant or Agent Dafe