HomeMy WebLinkAbout0061A 2928A (4) WORKERS'COMPENSATION DECLARATION 2�J �
APPLlCATiON FOR BUILDING PERlU11T 4
� " I he�eby afiirm Iho�1 hove a certificate of tonse��to self
insure,or a certificote of Workers'Compensation Insurance,
or a cenified copy thereof(Sec.3eW,lab.E.� COUNTY OP LOS ANGELES BUILDING AND SAFE7Y
PolicyNo���r D�� Company SvnG�r�. Nafi,eN,r�
� Cenified capy is hereby fumished. FOR APPLICANT TO FILL IN BUILD�NG U � a�
ADDRESS
�Certified capy is filed witb the county building inspeo- gUqp��
tian departmenl. . qooRE55
U01e �d�I `�'( Applicant n/�'L W 4`S✓�- CIiY ZIP IOCAIITV !+�C ���
CERTIFICATE OF EXEMPFION FROM WORKERS' NO.OF Bl�GS. NFAREST
COMPENSATIq�INSURANCE S�ZE OF i0t NOw ON lOT CRO55 ST.
(This seclian need not bo completed if the parmit Is for one 7RAC7 / BLOCK LOT NO. � �R
hundred dollara(�100�or leu.) MAP BOdC PAGE PARCEI
TEL. �zONE M!W
I cenify�ho�(n the performance of fhe work for which Ihis �'NER NO. � � /!� ^3'3
permit ia luued,I sholl nOt Bmploy ony pefson in any monner qDDRE55 �'�� �� SPK�a' O'
w os lo bocoma wbject fo the Worke�s'Comp�nfalipn�pws. CANDITIONS
CITV ZIP � V:
�ate App4itant ARCHITECT OR � TEI. �.
� 7TICE TO APPLICANT: If, pF1er moking fhis Cerfificote o} DISTRIR GROUP 7YPE FIRE PROC�SSED BY O
emption, yo� nhould b�eoma subjecf to the Workera' ENGinIEER �� �ppyST. 20ME F-
Campenwtion provisions of rha Lo6or Coda,you muat forth- q�RE� � S �� /f�� W
wllh tomply with �uch provision� a thi�parmil sFwll ba
dsamed revoked. ��/ � STATISTIGiL CLASSIFICqTIDN APf. CANOp, N
IICENSED CONTRACTORS DECIARATION CONTRACTOR �{L6L1.W �ron^ S.-�,vo.Zl3 63¢•�133 •
C �p� p IIC. CU155 NO. DWELL.UNI7$_ ?
I hereby affirm rhat 1 am licenmd under pravisiom of Chapter 9 ADDRE55 Z�dtr�.fu¢G�4i�trLf. Np.�3 S/D7�
(tommonting with Section�000)of Division 3 of�ha BuNrre�a�d .P L � LIC. 3�'�R NU1P
Professlons Code,and my litense Ia in full forta and eNec�. CITV .�1 /�'ribpUni n,q�5 B VAUDATIOH
S(i.FT. NO OF Np OF CNECK �. �'.
LitanaaNumber �357� IIc.CIo� SIZE � STORIES Zr FAMILIES ONE
Contrxtor��W 4���I ata � gJ ��R iOt�O�WORK � VALUATION
NEW
A� 4 C� l7 �GOb1 A
�I am exempt under Sec.
ALTER �f� • • �2"
0.8P.C.tor thi�reason REPAIR s
pO1e: us�oF � I • 1 1 i.4[:.
Fxisr� �p�. ! � �a ❑
Sipnatura '1`P��GM � �NE� � HNAL • • � � %.`"('_
OWNER-BUILDER DECIARATIQN PR�NT OATE �^�'��
1 hereby offirm that 1 am exe�npt from the Gon�roctw's License pDDRE55 h/� � / i, ��,L 2-U�
Low for the following reaaon(Section 7W1.5,8usiness and FINAL
Profsasione Code): �-�-- -�� -- -���-�- - 9y
j � BUILDING
� 1, os owner of the property, or my employees with ADWiESS
� woges as thair sole compensaiion,wifl do fhe work and ��y�ITY �
the strucWre is no�intended w offered far wle(Saction .
7044,Busineu and Rofessions CodeJ. MOV�NG h�. �L 7[;��F{
� 1,as Owner of the property,om exclus�vely conhatfing NTRP'ROR Np.
with Ifcensad contratton to construct tha projeCt(SeC- qDORESS �++ • o e �
tion 704I,Business and Professions Code).
CONSTRUC110N LENDING AGENCY �Qgq� VARD Hwr TOiwl sETenCK � a � 4 y^`�
7ROP.LINE WIDTH
I heraby affirm that there is a conslruclion lending agency fw FROM
�u j �;�C.,:
the ps 'vmance of the work for which�his permi�is issued p.t. _,.
(Ser Civ.C.). SIDE ��
V.L I �,O �-Lt�
� ^ ` �-+ lOHV1 Ref.M
� ' 7.C.fee S � I t Mmit Pee / �
�d this applim�ion and state that the luuanc•Fae j0-� tDMA P2 N �
\ �ct.I oqree lo tomply wilh all Counry Investipotion Fee �[,(�
"felating b building conshuction, iowl Fae ,T/��� IDNW perm.M
�nmtivas of�his County to enfer
��perty for inspectlon purposes.
� /�_ fE!REYERfi f011 E](�LANATORY LANGUAGE V
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