HomeMy WebLinkAbout1074A (5) - WORKERS'COMPENSATION DECLARATION . ��
I hereby offirm tha�I have a terfifitate of�o�,e��,o self , , - �� .APPLICATION FOR BUILDING PERMIT
insure,or a certi(icote of Workers'Compenstion Insurance,or
a certified copy�hereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY
PolicyNo. Compony
� CerriRed copy is hereby fumished. FOR APPLICANT TO FILL IN nooeess o?//� �iu��
� Certified copy is iiled with ihe county building inspeo BUiL01NG !p n / � /J �
lion deparlment. ADDRE55 �I/ /�N Le��7� LOCALITV �«..w�+e�� ,p s(�(/
� / NEnREST � ��
Dale Applicanl � CITY � Hph�/ Qr ZIP fROS55T.
CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. ASSESSOR
� COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MA7 BOOK 7AGE 7ARCEL
(This section need no�be mmple�ed if the pe�mit is far ane //n n u5e zONe hwP .
hundred do�lors(5100)or�e55.) TRACT �(/(+d/ BIOCK lOT NO. /Q �/ Np. }
TEL SVEGn.L d
OWNE ., rhPr NO. ��d CON�ITION$
I cerfify that in the performance o!iha work for whi<h ihis 0
permil is isz�ed,I sholl nol employ any person in any manner DISiRiCT GROUP TYPE FIRE PROCESSED BY V
AD�RESS � � //�S HJ� CONST. ZONE
so as�o become subjec�to Ihe Workers'Compensation laws. �/ • �
� 1/ � CITY � /11D/�L/ /� ZIP /a '�3 � � ,
Do�e AppliCont STAi1511CA1 CLASS�fICA110N APT. CONDp. V
NOTICE-TO APPLICANT: If, oifer moking fh icaf of /RCHITECT02 � 1EL � W
Exemption, you should betome suble[i fo fhe Workers' � ENGiNEER NO.- CLASSNO.�� DWELL.UNITS_ f1,
. Compensoiion pro��sions of the Lobor Code,you mu5/forih- ADDRESS SEWER MAV w
Z
with comply with such provisions or �his permit shall be TE�
deemed revoked. � CONTenCTOR(/fF •No. BK. PG, VALIOATION
LICENSED CONTRACTORS DECLARATION �J i��, �
I herehy ofFirm thot I am licensed under provisions oi Choprer 9 A��RESS /�� �'¢ NO. � VALUATION
Pmmmencin wilh Section 7000 of Division 3 oi the Business and /�/�
rofessions Code,and my license is in full force ond ef(ect CiTv/�.C+• 9/73v c1A55 C—�q S �U'¢'�
/ $Q.FT. NO.OF NO.OF CHECK
li[ense Number ��Oa �ic.Class L � SIZE ' $TORIES FAMI�IES ONE
Contracto�V�r�T����'f Dofe Z�� DESCRIPTIONOFWORK / �P NEW ❑ s .
� I am exempt from the licensing requirements os I am o G 7�as � ADD � �
licensed archi�ecl or a registered professianal engineer _ , ALTER � FINAL
acting in my prafessional capacity (Sectian 7051, REPAIR � �ATE
Business and Professions Code). USe OF DEnnO� FINAL
� E%ISTING BLDG. ❑ g
Lic.or Reg.No. Date nPPIiCANT iEt. Y
OWNER-BUIIDER�ECLARATION (PRINT) NO. w�� � _ nn_
I hereby offirm Ihol I am e�empt from the Contraclor's license _ /�=�+'�� C�� �� ��],�j A
law for the following reasan(Sec�ion 7031.5,Business and ADDRESS .
ProfessionsCade�: -��'�n,; ��„�, ,�/vt�z-C�Gi.. ���`• • • • �
OeUiLDING V �
1, as owne.r oI the propeny, or my employees wilh ADDRESS � • �3 1,5 0
woges as�heir sole compenso�ion,will do Ihe wo�k ond L N 7(�• GJ�Z��f1L
fhe structvre is not inlended or offered for sole(Setlion LOCnuiv
70d4,Business and Professions Code). MOViNG TEI. �p/�/�z �h,��V��� • • •3 1,5 0 c=i
� I,os owne�Of the properly,om ezclusively Contracling fON7RACTOR NO. ( �/- '
with licensed coNrodors to[o�strucl the projecl(Seo- qDDRF55 YLU'1�� � C 7.{— �2 2� �a'�
lion 7044,Businesz and Proiessions Code). J��� �
� REOUiRED TOLAL SETBAIX FROfd ExIST. at �:
i, CONSTRUCTION LENDING AGENCV SEi BACK �AR� HV"Y PROP.uNE wiDiH �p �� '�+" � ��e..�. '
' I hereby af(irm�hoi ihere�s a construction lending agency for FRONi '
�he performance of the wo�k for which Ihis permit is issued P L. � — /� �
(Sec.3097,Civ.C.). SiDE � 'K/,� it_�/y�
P.L. V
Lender's Name _ ��� M/�j��j�
.-. /v G
m ' Lender's Address . P.C.Fee 5 Permii Fee `,
W I certify ihal I have reod this appiimrlon and sraie�har the �ss�o�ce Fee 6'�v �v�v �(/l��T� ` .
Qobove in(ormotion is corred.I ogree ta comply with all Counry i„�esngonon Fee y7
g ordinances and Stote iows relating to building mnslruclion, � Torol Fee ��(/ '
and hereby outhorize representolives ai this Counly to enter
mopon fhe bove-menfioned properfy�or inspeclion purposes. � .
a �����/Ji� _1,(�/. . . SEE REVERSE FOR EXPLANATORY LANGUAGE
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