HomeMy WebLinkAbout0060A 2927A (4) , WORKERS'COMPENSATION DECLARATION �
� I hereby affirm that 1 have a certificate ot consen��o self � App��CAT10N FOR BUILDING PERMIT
insure,o�a certificate of Workers'Compensafion Insurance,
or a wr'�'�fviedd copy�hereot�Sec.3800,lab.C.� . COUNTY OF LOS ANGELES BUILDING AND SAFETY
Volicyl�'� ���Company�vOLN.IOrIAJ/}7/Bua,,,
� Certi4ied copy is hereby Pum�shed. FOR APPLICANT TO FILL IN BUILDING /► �
� Certified copy is filed with ihe nly building inspeo BWl01NG ADDRE55 `� �/ �(q��r p� �
tion deportmanT. A�DRE55 �/
�pie � ` qpPlica - CITY ZIP LOCALI7V !'jQI�/
ER Ifl ATE OF EXEMPTION FROM WORKERS NO.OF BlDGS. IVEAREST
COMPENSATION INSURANCE 512E OF lOT Npyy pry 1p7 � �gp�,5 gT
(This seciion need n01 6e compleled if 1he permit� or one TRACT BLOCK LOT NO. 8� ��R
hundred dallors(E100)or less.) MAV BOOK PAGE 7ARCE�
OWNER q USE ZONE tiV+� �.
I certify that in the parformance of tha work for which this �� � ` �� r10. �(� �
permit is ia5ued,1 sholl not emploY any person in ony manner R •v y/v�lf1 SPECIAt
so as fo become fubjecf to�he Worken'Compensaliort Laws. ADDRE55 r�� '[rl CONDinONS �
Dote Appliton! CITY r ZIP ' J �,
9TICE TO APPLICANL• If, ofler mnking this Certificote of ARCHITER � TEL. pI57RIC7 GROU7 tYae FlRE WtOCE55ED BY O
� .em lio�, � ENGINEER P NO.
p you ahould become su6'ecl to the Workers' CO 20ni F-
Compensation prorisians of tlw tabor Code,you must fonh- qpDRE55 2� � �Q n � � W
with comply with a�ch provisions or this permii shall be �x
deamed revoked. . � L i TEL. STATISTICAL CIASSIfiCAT1�N arr. c oo. tn
CONTRACTOR ('f}M�Wa 7}�. NO.U,�"J6� '?yI Z
UCENSED CONTRACTORS DECLARATION p C' �� 9 ���, CtASS NO. �WELL.unui5
I hereby offirm tFql 4 om licenaed under provisions nf Chepter9 ADDRE55 U Z�Qpyrl,Q,•�ae7.��! Np,�*3��
(commencing with Satl�on 700p)of Division 3 of ihe Business and ��� � SEWER nAAv
Wofeuions Coda,and my license is in iu11 force and effect. Ciiv A.iQyl�- CLA55 b eK. r�. vw�wnnoa
SCi.FT.t; NO.OF 9 NO.OF CHECK
LlcensB Nvmber �� Llc.Class� 5¢E 75S 57021E5 [� FAMIlIES ONE
._ ..... .,.-'--' .. ..._ � . . - AiUA - . .
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COMrottor ��9iM�Wt'�aIL��Dole �0 '�U DESCRIVTIONOFWORK NEW � . .. .
_- '.�"�_7n�
❑I am exemp�under Sec. '°DD � � z 0 Q b.Q A
AtTER
B.BP.C.4or this repson REPAIR � ---f- - - - �• • • �2 3
Dole: %5$TNG BLDG. 1 2. °EM1Aa I •2 0 5 2 8
Signoture ��PRIMr (�' NO.I� '7 FII'!Al F =
OWNER-BUILDER DECLARATION � r pq� ��'�C� ••Z(i...`z C��Z>
Iherebyaffirmfhallome:CR+qifromtbeCantrocior'sLiwnse qDDRE55 � . ) ��69l.-/�C«il )�.f
Low for the following reaion(Set�ion 703I.5, Business and � . ..� fINAI � Q 7,2 2—��C
Roffssiorts Coda): gy
� � BUIt�ING
1, as owner of�ha properly, or my employeea with ADDRESS
wages as their wle campensat�on,will do the work and �
the ahucture is not�ntended w offe�ed for aele(Seetion ���ITY
7044,Business and Protestions Coda). MOWNG . ift,
� 1,az owner of the properfy,om exdusivaly Conhacting ��RACTOR NO. �,
wirh licansad conrmcton to consiruct ihe projact(Sec- !I
tian 7044,BusinBsS and Profeesions Code). ADDRE55 �^
UIRED TOTAL SEiBACK L S�Z�7 A.
CONSTRUCTION IENDING AGENCY SET BACK YAND HWY pRpp,��NE Wi�TH
I hereby affirm tha�ihere is a construction lending agency for FRONT �:�� • • • �
the parfwmance af�ho work for which this permif is issued 7.t.
�s«.3om,c�.e.)_ sioe I •2 5 2 G C
v.�.
Lender's Nome � .����-;J�
$ •a� LDMA Ref.Y
£ lendei b Add�ess P.C.Fea S Permii Fse � i .�.C 7_:��,
y� I certify thal 1 have read thia application and atate that the Issuance Fee �•� LpMq p/C N
° obova i�fwmo�ion is correcr.I agree to comply with all Counry Inveelipution Fee w/�.�
8 ordinancea and State lows relat{ng to b�ilding construction, Torol Fee ��"J �(� LpMq perm.M
and F�ereby ou�horize repreaentat{ves of�his Co�nty to entar
� upon Ihe�agb,o�ve�-m�en ionAd p�operty for inapec�ion p��posea.
� �f.�-+!'I V�`.�'�l� J� sai aEVc�roR ExruN�rom uucu�cE
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