HomeMy WebLinkAbout1178A 1179A WORKERS'CDMPENSATION DECIARATION �
, v hereby'offirm ihal�have a�g,�;f;�a,a o,�o�,��,�o.��f APPLICATION FQR BUILDING PERMIT
�nsure,or a.certi4icate of Workars'Compensotion Insurance,
or a certified copy�hereof(Sec.3800,La6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �
Policy No. Compony
Carlified copy ie hereby f�miehed. BuitDiniG
FOR APPLICANT TO F�LL IN ADDRE55 2�07✓7 P.r17x/F/�vLL�i��eQ
� Certifiad copy ia filed with iha counry 6uilding inspet• BUaDiNG � ��� / ��y, n�
tian dapartment. ADDRE55 �d �S.rF,.ea� a�q/ho�u0 4A�
oore n�u��r aTv -D•A/'11a�'-A�> �AenP �acnury
CERTIFIGqTE OF EXEMPTION FROM WORKERS' SIZE OF lOT NOW ONB�LO � C OSSSST. ��7� C�{N�7.t� Q./�
COMPENSATION INSURANCE
(This saction need noi be complerod if the permit is for ona n55E550R
hundrad dollars($100)or less.) TqACT BLOCK LOT NO. � µqp gppK pqGE pqRCE�
TEI.'j USEZONE MAP
I cenify that in the perfarmance of rha work for which thia OwNER� / Np. � n ryp �(as �
permif ia lssued,I sholl nol employ ony penon in any monner qppRE55 7G'f L- )[//�'[L �JfJ17���0 `~� ���A� �'
so of to become subjeci to 1Fie Workers'CompensaHon Lawa. / �! COND�TIONS �
Dafe [IlY rI�V��� ZIP 94!�T Vi
li
NOTICE TO APPIICANT: If aher making�this Certificple of A��R� ��' DISTRICT GROUV ttPE FIRE 5 DBY O�
EMe lion, ENGINEER DL�J NO. Z�G� �pµ�T ZINJE U
mp you eheuld beeeme subject to fhe Workere' Z �_ � � W'
Compenaotion provisirnn of rhe lobor Code,yo�must forlh- ,4Dp�� `
wllh comply with such provisiorre o� this permif sholl be �l STAi15TICAL CtA551FICATION . COf�O. tn
deemed ravokad. �pryrytqRpR NO. ! '�� +f � � Z
LICENSED CONTRACfORS DECtARATION p�. .. _ QA55 NO.��—�'1ELL UNITS �
I hereby affirm thot I om litensed under provisiom of Chopter 9 ADORE55 Np,
{commencing with Section 7W0)of Diviaion 3 of the 8usi�eu and �� SEWER MAP
Profassiens Code,and my license is In full force ond affacf. CITY . CY?.55 �BK� � VALIDATION
SCi.FT. NO.OF NO.OF CFK_CK
LicenanNuml7er Lic.Class SIZF �� . STORffS � FAMIt1E5 ONE
DESCRIPT�ON�WORK .��1ISIJX.L GL/f�GC.� NEW � VALUATION pO
COnlrp�tOr �b O s /) �.�1./1• � _
A� 4 [/CJ
�I am exempf undar Sec. C,�J�7� CGk��
p�,�,.- ALTER
B.dP.C.for fhb reawn �!'s �PA�R ; 1 1 1 7.8 A .
Date: USE OF /�C� DEMOI #� • • �L 3
EXISTING BLDG. arr��G�3
Signafure APttIUWT TEL.
OWNER-BUILDER DECIARATION ��M P��JfF/��L�,�T NO. ` pA� � • '2�,b 3
I F�N�by offirm that 1 am saempt from ihe Contractor'a License �ppqE55�7�4Z��'Rf�/-� l�d-�����9�� • ' •2�.6.�,c`
Law for ihe following rea�on(Seetion 7031.5,Business and FINAL,-y
Professions Code): pRE ' � M� f Q 1 4-8%
❑ BUILDING
I, 06 owner of the proparty, or my employees with qpDRE55 z 1 i 7.9 A
wagen aa�heir sole compsnsotion,will do�he work and
�he structure ia not intended or offered for wte(Section ����TY
7044,Business a�d Professions Code). MOVING IEL. �� � � • • �
� I,as owner of the properfy,am e.clusively cantrading ONiRACTOR NO.
with licensed mnhvctors to consn�ct The projecf(Sec- qDDRE55 ' • •4�'G�
tion 7044,Business ond Professiona Code). - ,__ fr`' �„+ ., 4�J�U
CONSTRUCTION IENDING AGENCY SEi BACK YARD HWY T�TAp p1P IINE WIDTH �y � �,t • • •
I hereby aHirm tha�there is a conetrucfion landing ogency for FRONT I Q 1 4-8 7
the performonce of the wo�k for whith this permil is iesued F.L.
(Sa[.3097,Civ.C.). SIOE
V.L i �,•�J ~:'-i�`:.f�t
Le�der's Nome—�1r�E -" `
F� LDMA Ref.M
m Lender's Address�'L�' P.C.fee S Permit Fee
� I certify tfrot I hove read this application and atote that ihe iu�ance Fea � tDMA PiC M ,
abova informotion is corroci.I ogree to comply wilh all County In�es�po�;on Fea
ord�rwntee and 5 e ow ing t uilding consirucfion, Towl fee IDMq pxm.M
a d her au�h ize representa o ihis Counry to enter
� u on ih a ve- ionad pr ar inspection purpo s.
9 `d t
'� SfE REVERSE FOR E]lRANATORY LAN6UAGE
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