HomeMy WebLinkAbout1248A (9) WORKERS'COMPENSATION DECLARATION . �
I hereby offirm�hot I have a�e«,,;�o,e of Cpnsent to Se�F APPLICATION FOR BUILDING PERMIT
insure,or a cerlificare of Workers'Compenstion Insurance,or
a certified topy ihe�eof($et.3800,lab.C.) - �OUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyN ��� Company ��6�r�- �U/�t17. 'l
� Certified copy is hare6y fumished. FOR APPLICANT TO FILL IN ADDRF55 �G' 3�✓ -�=-�/!��-+��f <-c
� Certified capy is filed with the ounty boilding inspeo- BUiIDING '2 1 / • l/
tion departmenr. qooRE55 �) � F � � �OCnLlrv ��+_,a�C�
� � NEAREST (- �/ � //i`
Oate�-/Z-�Applica / CITY Zi7 - CROSSST. �>. /(��LL<-G�-C�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE � SiZE OF�Ot NOw ON tOi � MAP&OOK GAGE �ne�El -
(This section need nof be compleled if the permit is for one n 1C � /� USE ZONE MAP �
hundred dollars�5100)or less.) TRACT�// 1 eioCK lOT NO. �/� No - .�..�-=� r
� � TEL. �" SFECIAL �y
I cerliFy Ihal in the porformance of the work for which Ihis OVfNE .$ NO. � Q � /���vv CONDITIONS O
��� ^ �ISTRICT GROUP TVFE FIRE PROCESSED BY
permit is issued,I shall not employ any person in any manner — V
ADDRESS i 1 - CONST.� ZONE
so as to become subject to the Workers'Compensalion lawz. � �� G:
crtv 0 V 1 w il- zia '�� � !L a._e_r,c/ O
Dale App�icpnl `_ STAiIS11CAl ClASSIFICATION APi. CON�O. V
ARCNItECT OR TEI. � ��
NOTICE i0 APPIICANi: If, after making this Ceriificaie of EnlGweeR - NO.�- C�A55 NO..�:1_DwEu.UNi15_ � a
Exemption, you should become subject �o the Workers' y
Compensalion provizions of the tabor Code,you musl farth- ADDRESS SEWER AMP Z
wilh comply with such provisions or this permit shall be TE�. (/
deemed rewaked. CONTRaC . (, � _ { No�3�- � BKJ S PG. YALIDATION
LICENSED CONTRACTORS DECIARATION iC.
I hereby affirm that I am Lcensed under provisions of Chopter 9 AQ�RES � ���(-� _��i� 'v J NO. � ,� ypLUATION
(commencing wilh Section 7000)of Division 3 of the Business and ` t,, LIC. 1
Professions Code,ond my license is in full farce and effect. � CRY d�/)vl ry- CLA55 -1 S (p l�f0� Q"�
� c � SQ.FT. 2 NO.O NO.OF CNECK
Li[BnSe N��Jtnber/���J./�7� Li[.Class� I SIZE � J STORIES / FAMILIES � ONE
Con�r$tt�"��.�.�/��_lCl�W1� te _f-/�-�� DESCRiPTION OF WORK . NEW � S
� I om e.empi from ihe licensing requirements as I am a � �77��OM ���)�'� b v�, ADD
licensed orthi�ect or a registered professional engineer aL�ER � FfNAt y i( �
octing in my professionol copocity ($eUion 7051, REPAiR � �AiE � � �
� Business and Professions Code). � uSE OF
' � Ex157ING BlD�q- `� .�� DEMOL ❑ -FINAL,A�
Lic.or Reg.No. Date '� APPUCnN . TEL. C gY ���"����
- - OWNER-BU1lDER�ECIARATIDN. � IPRM ��-� /' � L. S(Jw-u10. �Z^ !� ��2 Q'a A
.._ . ___ . _' _ "__
. . . . .. . ....... . . . ... '_ _" �_._..
� I here6y affirm thm 1 am axempt from Ihe Comractor's License � C-- - � ---- -----"-- --���--�� - ----- - --
� law for the following reason(Settion 703L5, Business and nooaess: �W�`l-F1 l_1_ n Y?_n i S 1 � �6 �V �.� � � � ���
f ProfossionsCode): . _. . . ppE EN
aBUnOiNG 1_•_•6 1,5 0
I, as owner of the proparty, or my employee5 with ADDRE55
woges as their sole compensalion,will do the work and r r .6 1.5 0
the slructura is not iNended or of(ered for sole(Section
LOCAIITY V
� 7044,Business and Professions Code). MOViNG 7[�. ���� 2-8 2
� -� I,as awner of Ihe properhy,am exdusivaly coNrocting �ONTRACTOft NO.
with licensed cantroctors to consiruct the projecl(See � ADDRE55
tion 70a4,Business and Professions Code).
CONSTRUCTION LENDING AGENCY REOUIRED TOTAL SETBACK FROM EXiST.
SET BACK YAR� HWY p�pp_LINE WIDTH
I hereby offirm tho��hcre is a mnstruction lending agenty for FeONT
' ihe performonce of the work for which this permit is iswed v�
' . (Sec,3097,Civ.C.). SIDE
P.L.
lender's Nome ',�7
j m . P.C.Fee S Permii Fee J'�3- v V
lender's Address v
W I cerlify ihai have read this applicotion and s�ote thar the i,,,,�„Ce peP p. S U �
Qabove infor tion is correU.I ogree to wmply with all County In�esi�gaoon Fee �
ardinonc nd Slote laws relafing to building construclion, ioiol Fee ��- S�
� and her y ouihorize representotives of Ihis County to enler
aupon a6ove-rt/1entioned//ffyyu/q�,����"%}', inspet ion purposes. �
a (Llc.� ({K` l l./���1J�'�V / i
/ W SEE REVERSF FOR EXPIANATORY LANGUAGE
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