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HomeMy WebLinkAbout0648A (4) WORKERS'COMPENSATION DECLARATION � iI I hereby af(irm thot 1 hove o�e�„f;�o,�of consent ro,e�f qpp��CAT10N FOR BUILDING PERMIT �nsure,or a certifico�e of Workers'Compensation Insumnce, or a certified copy the�eof(Sec.3800,ta6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Compony � � cen�fied coPy;s hereby fu.��ihed. fpR APPUCANT TO FILL IN swi�iNc /�7 0 ,µ ADDRESS �(.j{,(L � Certified copy is filed wieA�he county building inspec- BUILDING `� lion depprfinent. ADDRE55 v� t Do�e App1;<om crtv zir �ocaurr i CERfIFICATE OF�E?(EMPTION FROM WORKERS' NO.OF BtDGS. NEAREST COMPEN5ATION INSURANCE S�ZE OF lOT Wow OM l0T CRO55 ST. �ihii aettion neod not be completed if the permit Is for one ASSESSOR : hundred dailan�5100)or less.) T��T BLOCK LpT tJO. - �yqp gqq� - PA� PAR�� 7EL. USE ZIXJE j I certify�hwt in the performance af the work for which this �NER b � , permit is issued,1 shalf not employ any person in any monnor ���q� b w as fo become subjetf 10 tha Workerz'Componqtiort Laws. A�RE� 0 CONDITIONS Date Applitont CITY ZIP ,�✓� � NOTICE TO APPIICANT: If, after making this CerTifi�ate of ARCHITER OR {� TEI. � DISiRICT GROUP TVPE FIRE PItOCESSEp gy � ENGINFER 1 NO, OF Examplion, you ahould 6rcome subject to Ihe Workers' / � CON;j�c ZONE Compgnsation prorisiona of Ihe lobor.Code,you muat forth- qDDRE55 v �v 0. with comply wilh wch provisions o� lhis prrmi� chal! be desmed revokbd. CONTRACTOR � N� STATiST1Ut UASSIFKATIpN qpT. . z LICENSED CONTRACTORS�ECLARATION .�y�,� � ClASS n1p. DwEtt.UNITS 1 haraby offirm thol l om litensed�nder provisions of Chapter 9 ADDRESS Q 16N' MB (wmmencing with Section 7000)of Dirision 3 o11he Business and ��� SEWER MAV Pro}essions Cods,and my licensa ie in full fpce ond effect. �iry � ��q� ���AT� SQ.FT. NO.OF NO.OF CHEIX BK. PG. LicenseNumber Cic.Class SIZE STORIES FAMILIES ONE � v�uuanon �ESCRIP710N OF WORK �W Conlr«�or Date ❑ S nDD �I om exempt�nder Sec. A�.�R � �0 6 4 8 A B.BD.C.fw fhis reown REPAIR � _ #• • . •�v Dale: USE OF exisnnic e�oc. °E^AO1 I • •�5 0 0 Signoture APPIICAM TEt. FfNAL OWNER-BUILDER DECIARATION ��NT N�' DATE • • I hweby affirm thu�I am exempf from�he Cantracror's License •2 5,',�;ri' Law for tho following�sason(Soc�ion 7031.5,Business ond ADDRE55 F�� �&��—8� Roieaions Code�: R „ _- . . . 4y � I. os owner o(the property, or my employaes with q��g� wogos as iheir sole tompensa�ion,wilf do the work ond � �he ttruclvre is nol intended o�offered tor sale(Section ����T'� 70A4,Businesa arrd Profeaeions Code). MpViNG 7Et. � 1,as owner of the prapeHy,om axclusively contracting ��NTRAttOR Np. with Ilcensed conhacfors to mnslruct Ihe projett(Sec- qDDRE55 /� � rion 7044,Business and Professions Code). }�/ � CONSTRUQION LENDING AGENCY ��q�K VARU HWY T�Tp'�p��INE WIDTH ��4C.G._. I hereby affirm that Ihere ia a construction lending a9ency for FRONi U the performanw of th�wwk(or which�his permi�is iswed p.�. (Set.3097,Civ.C.J. SIDE P.l. �ender's Nome n�^ Lender's Addross P.C.Fee S d�l•� Psrmit Fm ��ReL X � I cerlify tFq/1 hava read ihia applicotion and state ihot the Iswonce fee L�MA p/C N � � above infwmation is conect.1 oyrea lo comply with all Couny Inveatiqo�ion Fee 8 ordinonees and State laws relating to building wnslruction, Toal Fee IDMA Perm.M ' and heraby Ihorize reprasantat' e of thie County to enter aupon t - en�o e op 1 for inapection pyrpo s. S/� SEE IIFVfpf!fOR iYW�INATORY LANGUAG! Signawr�o{App icoM or Apsnt � , ,L` 4, t y _ y u ` � N C y v. ., � ' . p �T',�,'. � «~ t� C, �c. � � .r.'~ y V r y ' .�.::.� n,a � 7� .C� � � C u vr•+ r 4 v L LL ` t . F �:� fi�� �.C 3 '� `�'�` ~ �' a w L C., y' O •�.. � � � u L `� 11 ' ` 7 f� ,n i. 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