HomeMy WebLinkAbout0059A 2930A WORKERS'COMPENSATION DECLARATION �
� ' I hereby affirm ihat 1 hove o cenifica�e oi consen��o self APPLICATION FO�t BUILDING PERMIT
inaura,or a certificote of Workers'Compensation Insuronce, t
or a cert�t�ed copy theraof(Sec.3eoo,�ab.C.) , CpUNTY Of L05 ANGELES BUIIDING AND SAFESY c(7-�.h,L�01�
PolityNtic�-�r�Cort+pa^YSvP�z►� N�+e�� BWIDING .�r n
� Certified copy is hereby iumiehed. FOR APPLICANT TO FILL IN ^ ADDRE55 �� � V v�l CN Nh•
QCerlified coBY�s filed with the county b�ilding inspec- BUItDiNG /� rr �
tfon deparfinenf. ADDRF55 � U �
Dala
1��� Applita�t �k��^^"'l��i CISV ZlP tOC4lITY �Qn..^�+`� ��
CERTIFICATE OF EXEMP710N GROM WORKERS' ������ NEAREST
COMPENSATfpN tµSURANCE SIZE OF lOT NOW ON LO7 CRO55 Si.
(This section nead not be completed it the perrt�ie i�ior one A�'�R
hundrad doliwa(t100)or less.) TRACT 3� ' BIOCK l0T NO. ¢� AM1AP BOOK PAGE PAR�I
owr�R '�_ use zor� � �i
I ce�tify that in the performonce of the work for which thia �� l r���f �
� SPECIAL O'
permit ia i�a�ed,(ahal)not emplay any person in any monnar A�RE� � g �( �� �DITIONS
so os to become wbject fo tha Workers'ComFunwtion[awe. V
CI7Y g Z�P �'
Dote Applimnt ARCFtITECT OR NO. DISiRICT GROUP NVE FIRE PKOCFSSED BY OO
� -'�TICE TO APPIICANT: It, oftar making�this Certifimte of INE R � ZONE
emption, you ahould become �u6jett to the Workers' ,i ��l W
Lompensalion provisiorn uf tho ia6or Cod�,you must fwth- ADDRE55 `� i, ��� �«I� �u �` � � Q-`
wilh tomply wilh such provi6ions or fhii pYrmit ehall ba t L STAT75TICAL CUSSIFICAiIOM APT. � �
deamsd ravoked. Cpo-iTRpCtoR Yl.�t Wl r7trx�, `L(3(�34"7�f �n� Z
IICENSEO CONTRACTORS DECLARATION �,s' �p�,.,�(��;_ - - Ct.455 N0.�LOWELL.UNITS
1 heroltY affirm thot 4 am licensed under provisions of CFwptx 9 ADDRESS i-b �"��'"'�'�"�'�O. �J�7�� gy�A MAi
(camme(uing with Senion 7000)of Divicion 3 of the Bualneas ond �, ��- UC. �
Profaaions Gode,and my licenaa is in full fores ond effxL Cttv C�u 8K. pG. y�'�dAT�
SO.FT.. NO.Of FMh1�5 CONEK
Lieense Num6er ����� ltc.Cfass -� � SIZE 1 STORiES �
Q YAWATION
� � qo DESCRIPTIONOFWORK "E"` 0 s 2G SOD
co��,«�o.A ern-nn�W �svh ��. „oo �
�I am e:empt under Sec. �� qLTER ��0�'�A
6.8P.C.far this�wson ��'�•lV�''- REPAIR ; #• • • •L 3
on�•: Ex�sT°Nc s�oc. r l.C. °EA''� I • 1 5�8 5
Sipnoturo �R��i � �t. FINAL
PRINT NO. L
OWNER-BUILDER DECLARATI�N p DATF -7, ���j •• � �3,;�J�
I hereby offi�m that I am exempt from the Contractor's Liti�ss ADDREu Z�Gi(} �� �7 0 4��+.f ,f I)•r�..(/ F1NAL
Low for the 4ol{awing rcason(Section 7031.5,Businesa ar+d � ./ ��.�2"'�8
Profeu7ona Code)� euitoiriG
� � 1, as owner of�ha propsrty, o�my employees with ADDRE55
wpye�Cs their sole tompanwtion,will do Ihe work and ���Ip, �
the structure ia�ot intended a o44ered for sale(Secfioa
7044,Businefs and Professions Cods). - MOVMG TEL.
� I,as owner of the preperty,em ezciusively contmcting ��TRACTOR ��
with(icensed comracton to construct�he project�Sec- qpDRE55
tion 7044.B�siness and Proiessions Code). ,
REIXJI D YARD MWY TOTA1 TBA K �,
CONSTRUCTION LEN�ING AGENCY SET BACK PROY.LINE wIDTH
I hereby affirm�hat�here is a construction lending agency for FRONT �2���� �
�he performance of the work fa which thie permit is issued P.L.
($eC.3097,Civ.C.). SIDE �•�� a �7
V.L.
Lendar's Nome � .� LphW Ref.M � � � C�'"�'
W P.C.Fee S l� Pe�mit Fee � � - :� _.
Landar's Addross � 1 '� i �' . .'
� I certify ihm�have read this application and slate thot the Issuance Fee ���� ��P/�k
obove informo�ion i6 corrett.I ag�ea to comply with all County �n.es��gation Fee / ,` ' �,C%—�.R
ardinances and Stote fowa relating to 6uilding construction, Total Fee / �•V � �MA Verm.M
R ond hereby authorize representatives of�his Counfy to enter
upo�the�+a6orrvo-men on Qroperty for Inspectio purpoaee.
M1 , I�/;���M���� !� � SEE RFVEYSE FOt EJ(HANATORY IANGUAGf
Y
Siprw�Lre of ApPIimN or Aqenl te
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