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HomeMy WebLinkAbout0061A 2928A (6) 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 iEl. �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 n r � � "s _.: � J F l r� O t� y. � C1 C .'4 . ,y CJ � � +1� a' T 4 .�`,. 1., � . CV a � ;� � 4.N Z O. `4� -d a ^�'-�,�% ' Y` ?' p � d t G.� '� � i W S 's G 3 �.c �-� � w r o c F :� „, m h . `.c�: ,^.�, 3 a.�' y.L �'^ �, 'Y�. '� a a��c.� � d G � j a� C a O � S'�^�J � F�r, n� � C 'V �n�„�"_ .:�..0~ 1r ��,,, �. u•ey' � t ✓ �tf,�.a�.n r 'V ,..; �i.�. C � T 2l✓� � r 1[ ..�� i +� � i� . 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