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. SiOE , {'�c. �:
v.�. �
Lender's Name �d�E �{ p p- IpMA Ref.N
$ P.C.Fee S �� 7 Pxm�t Fae �8'��7 �
Lender's Addrosa �'b►�� �
� I certify tho�1 hove reod fhie opplica�ian and sMro that the iawancs Fee � WAM P/G M
o6ove information is corcect.I ogree ta comply with oll County Inrost{goNon Fas
$ o dinoncaa Stafe laws rolating to building consfruc�ion, Tehl fes 2� I�MA Pmm.N
� ereby a oriz repisae ' thi�Counry to eMer
� he a v - ned pr er o inspeclion purpone '
� �g'' SEE REVERfE FOR E1[HANIhTORY LAN6UAGE
ignotura of App icom or Age De
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