HomeMy WebLinkAbout0648A WORKERS'COMPENSATION DECLARATION �
j I hereby af(irm that 1 have a�e�„f;�o,�of consent ro,e�f APPLICATION FOR BUILDING PERMIT
i ins�re,or a certificate of Workers'Compensation Insumnce,
or o cerNfied<opy the�eof(Sec.3800,ta6.C.) COUN4Y OF LOS ANGELES BUILDING AND SAFETY
Policy No. Compony BUILDING /7��p , _p„ ,
� � ce.+ticed coPy;s hereby 1v���ahed. fOR APPUCANT TO FILL IN ADDRESS ������'
� � Certified copy is filed wieA�he county building inspeo Bl11LDING �/
lion deporfinent. A��� " �
t DOtb A�1{iCOM CRY ZIP LOCALfTY
� CERfIFICATE OF E%EMPTION fROM WORKERS' NO.OF BtDGS. NEAREST
COMPENSATtON INSURANCE SIZE OF lOT NOW ON l0T CROSS ST�
�ihii aettion nrod not 66 completed if the permit Is for one - �S'� -
� hundred dailars(i1QU)or�eis.) T��T BLOCK LOitJO. MAP BOOK PAGE PARCEI
USE ZIXJE
� I certify lhot in the performance af the work for which this OwNER b NO.
permit is issued,1 shalf not employ ony person in any monnor ���A� d
� w as to become subject to rha Wor4era'COMp6nqtion IAws. A�RE� � CONDITIONS
CITY ZIP �Z �.
DatO App�kont ARCHITER OR `` 1 TE�� � OISTRICT GROUP ttPE FIRE PROCESSED BY O
NOfICE TO AP%ICANT: If, after making this Canifitate of ENGiNFER Ih'N �� / � CON��� ZONE U
Examplion, you ahould 6rcome subject to Ihe Workers' ��
Cpmpertsatio�provisia�a of lhe lAbor.Code,you muat furth' ADDRESS v J�� �
with comply wilh wch provisions O� lhis prrmit chal! be TEL STATiST1Ut CL4551FKATIpN APT. . (n
desmed revok6d. �
LICENSED CONTRACTORS�ECLARATION �NT��� ,y�.p,/ ? �u�. DWEtt.UNITS z
1 haraby offirm thol l om litensed�nder provisions of Chap�er 9 ADDRESS 0 16N" NB OG7 � ��R�y
(wmmencing with Section 7000)of Dirision 3 of ihe Business and uC.
Pro}essions Cods,and my licensa ie in full force ond effed. OTr 1 C�-45S BK � VALIDATION
5q.FT. NO.Of NO.OF CFIECK
LicenseNumbbr Cic.Class SIZE STORIES FAMILIES OME
� wuuanoN
�ESCRIP710N OF WORK �W
Conlroc�or Dafe qpp � s �
�I om exempt�nder Sec. A�.�R � �0 6 4 8 A
B.BD.C.fw fhis reown REPAIR f #• • . •�3
��e: ex sS r•,c BLo�. °E"`O1 I • •L 5 O O
SignOture APPIICAM TEt. FfNAL
OWNER-BUILDER DECLARASION PitiNi NO. �Tf • • •2 5,i,(;�
I hwoby affirm thu�I am exempf from�he Cantracror's License qDDRE55 FINAL
law for tha following twaon(Soc�ien 7031.5,Business aod � �����a�
Rofeaions Code�: �� -- � � r
o �,�,�
I,os awner of the property, or my employaes wifh ,o0ORF55
wagos as iheir sole tompensa�ion,wilf do the work ond L��ry �
�he t�ruclvre is eol imended or offered for sale(Section
70A4,Businesa arrd Profeaeions Code). /��� �l.
� 1.as owner of the p�apeHy,om axclusively contracting COhITRAttOit �.
with Ilcensed conhacfo�s to mnslruct Ihe projett(Sec- qDDRE55 i // � /�'L O
rion 7044.Business and Professions Code). ,j�yvw vi�•�,�
RE(.lU1RE� TOTAL SET �
VARU HWY /�`"
fONSTRUCTION LENDING AGENCY SEf BACK PROP.IINE WiDili V
I hereby affirm that Ihere ia a construction lending a9ency for FRQNi
the performcnw of tho wqk�or which�his permil is iswed P.L.
(Se[.3097,Civ.C.J. SIDE
P.l.
�ender's Nome tDMA ReL M
$ P.C.Fee S ��•� Psrmit Fm �
Lender's Addrass
� 1 cerlify�Fw+1 hava read�hia applica�ion and state ihCt the Iswance fee ��P��k
above infwmation is conect.1 oyrea 10 comply with all Couny ��reaiiyu�ion Fee
8 ordinonees and State lows relafing to building wnslrudion, Toal Fee IDMA Perm.M
� and hereby Ihorize reprasantat' e of thie County to enter
� uppn t4 - en io e op 1 for insQection p rpo s.
� g�g SEE IIFVfpf!fOR fYW�1NATORY LANGUAG!
Signawn oi App kom or Ap�nt
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