HomeMy WebLinkAbout0648A (6) 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
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