HomeMy WebLinkAbout1180A 1181A iWORKERS'COMPENSATION DECIARATION , �'herc6y;affirm that 1 have a certificate of�o�se�,�a aelf qpp��CATION FtJR BUILDING PERMIT insure,or o cerfifitote of Woikers'Compensation Insurance, I pr o cenified topy thereof(Sec.3800,Lab.C.) COUNTY Of LOS ANGELES BU1lDiNG AND SAPETY �. PolicyNo. Compony BWIDING ��. � Can'rf�ed copy ia hereby 4um�shed. FOR APPLiCfiNT TO FIIL IN AppqEu �)(77 ���ht-��Q � Cer�ified copy ia filad with tha county building inspec- suuDtNG /►���2 ����� -7�/A�n�f� ��.�• lion deparlment. A�DRE55 L. J S✓ /��^• Uate ApplicoM CITY •J!'`'t�0�p'""� i1P LOGIITY r� CERTIfICATE OF EXEMPTION PROM WORKERS' �'�et�s� 1 CROSSSST. l.JtiG� C�N7� • COMPENSATIOtJ INSURANCE SRF OF l0T . NOW OH IA7 �This seCtion nead nol be completed if fhe permit is fior ona TRAR BtOCK LOT NO. M�p,P BOOK PAGE PARCFL hundred dollars(E10p)or less.) �j}�/ ��g TEt.A �r OWNER rR�n��I�4��� NO.'7'7K��� USE ZONE NOP � �-�''3 33 }� 1 certify thot in the performance af the work for which thia SPELIAL d. permit is iswed,I sholl�ol employ any person in any monner +I��j Iu � w as fo become subjecf to Ihe Worken'Compeowtion Laws. AooRE55�/U'�� „y���E'� SU�rEf� �P� CDNDITIONS U; crtr�ieYlNE ziv 9'Z7/4 L• u �v- � � Dafe AppllcoN ���R pp DISTRI�f GROVV TYPE fIRE OCE55 D BY O NOTICE TO APPIICANT: if, ofte'moking this Certifimte of ENGINEER DWNE7e� p�j�p.����2Q�� � �OPAS� ZOrynl� V EKempiion, you ahould bemma aub�ed to Ihe Workers' � W Companwtion provisions of the Lobor Code,yau muse forth- ADORfSS a �"� ���� 'n- wi�h comply with suth p/ovisions or this permit ahall be TEt.y.yAr�� STATISTIG4L CL4551FIUTION nPT. [ON�O. Z deemed revoked. CpNTRq[TOR �Q /�� NO!'p/T � --�� LICENSED CONTRACTORS DECIARATION ���. CtA55 NO.��DWEIt.UN�TS I hereby aifirm thw I om licensad undar provitions af Chop�er 9 .aD�RESS NO_ ��R�p �rommencirg wilh Seclion 7000)of Division 3 o41ha Business and LIC. Profexsions Code,and my iicense is in fuil forca ond effect. aiv M55 BK � �� VAUDATION � SGf.FT. �^ NO.OF �7 NO.OF CHECK Litense Number Lia Clos• S12E �J STORIES L PAMIL�ES �E . ❑ VALUATION � DESCRIPTION OF WORK Gl�/¢((+ NEW ,p�� Conr.ocror Date s �V�'"'� � �I om exempt under Sec. � � �hp � �1 1 &6 A 9.&P.C.fo��his reaaan T� E .�EY�M REPAIR U f �• • • •2 v oo�e: erssrwc awc. [��F/LE'� oema ❑ 1 • •3 2 9 4 $i nature APPLIC4N7-�y A..�A PINAI • e a�j 2, �� 9 PRiM1 r'NTN'F/AJ✓'i 7�i �((� N0.7�`T���� n/ OWNER-BUILDER DEQARATION � �r,� Tp DATE I hereby offirm that I am exempt from�he CoMracror's License Ap�REu�?6/!2"`��{•j,L S�f/J�/�,�`�"r/� flNAL'/� � ��'� 4—�7 law for 1he followirg reosOn(Settion 7031.5,Business and � V v ProFessiOna COde)' FftES NT ��,� � �� A ❑ BURD�NG I,as owner of the properly, or my amployees wilh �. ApDRE55 wages as Iheir sale compensation,will do tha work vnd� � #� � � � �� ' 1he structure is not intended or offered fw avle�Section LOCAl1TY T084,Business ond Profess�ona Code). MOviNG TEI. ( • •4 4.2 5 � I,oa owner of�he property,am exclusively conttacling CONTRACTOR �� � � with(icenaed toMrocfon to comtruct tha projed(Sea' •4 9.2 5 c=.o AODItE55 tion 7041,Business and Profesaions Code). I Q� 4�8 7 CONSTRUCIION LEMDi�1G AGENCY ��BACK YARD HWY TO7AL�uNE WiD7H 1 hareby affirm thef Ihere is a construcfion lending agency for FRON7 Ihe perfumance of the work for which this Qermit is iasued P.l. . (Sec.3W7,Civ.C.J. 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