HomeMy WebLinkAbout0019A 0020A WORKER5'COMPENSATION�fCLARATION / 1.(/K�^G �
I hereby offirm ihot I hove o�e�,�f��a,e oF consen�ta self APPLICATION FOI� BUILDING PERMIT
insura,or a certifitate of.Workers'Compenstion Insurance,or
ayc'e tified gco�p,y Mthee(re�oyi( et.3800,l�aby.yCy.f)�> COUNTY OF COS ANGELES BUILDING AND SAFETY
Voli�Na+LY/Y/G'7/�Company%�//.GC7� ���j'
� Centfied co is hereb fomished. BVaDWG ��. .
av v FOR APPLICANT TO FILL IN aooRess /��G �
��V�/Certified copy is filed with the rouMy building insper BUILDING �v.
� tion departmenl. AD�RE55 ��3� � IOCP,IITy �
NEAREST
Date�Applico� CITY ZIP CRO55 ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE � SIZE�F LOT NOW ON LO7 � MAP BOOK PAGE PARCEL
(ihis section need nat he comp�eted if�he permit is for one USe ZONE MAP l/
hundred dollars�$100)or less.) . TRACT BLOCK LOi NO. �� NO. ���ji"� T
El SPECIAL � p,
I certify thot in ihe performnnce of the work foi which Ihis OWNER D ?� CONDITIONS (j
permil is issued,I shall not employ any person in any manner ,Q�� �'),`t r DISTRIC7 GROf1P 7YPE FlRE PROCESSED BV V
so os to become su6jecl�o ihe Workers'Compensation Law:. ADDRESS[70� 1�pY � (�{♦ �O �� CONS� ZONE O
Da1e Applicant ��TY Z�P STATISiICAL CLASSIFICATION APT. CONDO. V
�TICE TO APPLICANT: If, ofler moking this Cartificote of AFCHIiECTOk TE � 1'
mpfion, you sho6ld become subject ro the Workers' ENGWEER N CLASS NO. �� �WELL UNITS� � �
Campenso�ion provisions of�he labar Code,you must forth- AODRESS SEWEk MAP Z
wifh comply w'th such provisions or lhis permif shafl be
deemBd revOked. CONTRACTOR N BK. PG, VAIIDATION
LICENSED CONTRACTORS DECLARAT�ON
I here6y offirm thot I om license�-�...e.-r._.s__ns_of.S.64pter 9.,__ ADDRE55 ~f �� �O.
"'"'""'""' V ALUATION
(commencing with Se�lion 7000)of Division 3 of the Business ond �--""�--��'--�------ -�--- y— -
Professio�s Code,and my license is in full force and effecL GTY QA55 S�/' +���Q
-+�� SQ.FT ND.OF NO.Of CHECK
Li[e�se Num6er W�� lic.Class SIZE STORIES FAMILIES ONE
>� DESC&IPTION Of WORK NEW b
Conlract � ��Dote ❑
� I am exempf from the��censing repuirements as I om a ADD
licensed architect or a registered professional engineer ALTER ❑ k�A7� �C 0 L 9 A
acting in m,y profess�onol mpacity (Section�7051, �
REPAlR
Business and Professions Code). USE OF N �'� • •2�
E%ISTING OIDG. �EMIX � B
Li[,or Reg.No. Date APPUCP,N TEL n��h � •G 7�,v�
OWNER-BVILDER�ECLARATION IPRINT N •"7V �,L
I hereby offirm Ihat l om exempt from the Contraclor's license� �'�'� •.�2�]1,�2 czi
Law for rhe following reoson�Section 7031.5,Business and ADDRE55 'ZF
professions code): raeservi I ��� 5-$3
. � i, as owner of Ihe property, or my employees with ADORE55
wages es their sole compensotion,will do fhe work and - � •�
the struUure is not intended or offared for sale(Section ��CA��TY .
70E4,Business ond Crofessions Code). MOVING TEL �Q 0 Z C A
� f,os owner af the property,am ezciusively cont�octing CONTRACTOR NO. rt•� � � �1
wi�h licensed coMraUors to conslruct ihe projetl(Sec- AD�RESS
. tion 704q Business ond Professioos Code). I •/1 6�L 5 G
RE�UIRED TO7AL$ETBACK FROM EXIST.
CONSTRUCTIDN LEN�ING AGENCY SET BACK YARD HWY PROP.LINE WIDTH
I hereby affirm�hai there is o mnstruclion lending agency for FRONT . • �Q(,+F:F(��
ihe performance of ihe work for which fhis permit is issued p.L. � �
(Sec.3097,Civ.C�} ' � ,�. � sioe I �,� 5—8 3
�/,/���� � � P.(.
Lender's Name�[�if � a/ .
� - Lender's Address///ll�N�f��/T1��✓/1 � P�C.Fee S Permi�Fee �t jrli. P'� '
I cerlify Ihat I hove reod this applimtion and stale thol the Isw ce Fee �0•J`' �
above informotion is mrrect.I agree to comply wilh oll Counry Invesi�qmian Fee
$ ordin d S�ate laws rela��ng to building conslruUion, tomi Fee ��L• .��, ,
and ereby uthorize p sematives of Ihis County to enter
a upo ih ove(1�i e io roperry forinspection purposes. .
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a ,1/d SEE REVERSE FOR EXVIANATORY LANGUAGE
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