HomeMy WebLinkAbout1248A (11) WORKERS'COMPENSATION DECIARATION , �
I hereby of(irm thot I have a�e�,,���a,a of consent to 5a�f . qpp��CAT10N FOR BUILDING PERMIT
insure,or o certifica�e of Warkers'Compensiion Insurance,or
a certified copIy thereof(Sec.3800,106.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyN /�� Company,���r� �Uh11-�. /��
� Cenified mpy is hereby fu��ishe� FOR APPLICANT TO FILL IN ADDRE55 -�G' 3li' (�'
��
� Certified copy is filed with�he ounty building inspec• BUILDING 1 / . l/
tion deparlment. ADDRE55 � � /� jl-' IOCAIITV .�r-<<_IC/
Date � �� y Applico � ;� CiTY ZIP ` CROSSSST. �. /c�cclC��4
CERTIF�CATE OF E%EMPT�ON fROM WORKERS' NO.OF BLDGS. ASSESSOR S
COMPENSATION INSURANCE 5¢E OF LOT NOW ON lOT � MAP BOOK 7AGE PARCEL
(This section need not be comple�ed if ihe permif is for one TRACT i/J / � �/ u5E ZONE MAP
hundred dollors(5100)or less.) ,� BLOCK lOT NO. r7� NO. � 7.r2.`� }
� iei. �� SPEQAL Q,
OWNE S W NO. �SQ - �V Mcy�� CONDITIONS
I certify thal in the periormance af the work for which this 0
permit is issued,I shall not empioy ony penon in any monner �1 OiSTRICT GROUP iYPE � FIRE PROCFSSED BY V
AOORE55 {o - CONSTf� ZONE
so as to become subject to the Workers'Compensalion lows. � ^ /n � 1 ,/ � GY
CITY OV 1 W V�"' � 21P J . �+'� 2au.�/ O
OOfe AppliCanl $TAi15iICAL C1A551FICP.TION � APT. CONDp.
ARCNITECT OQ � TEL.
NOTICE TO-APPIICANT: If, aifer making Ihis Cerlifimte of EMG�NEER '� ntp.�— .�� W
Ezemption, you should become subjetl lo Ihe Workers' M55 NO. - DWELL UNITS_ n.
Compensaiion pro�is�ons of rhe Lobar Code,yoV mvSt forlh- qpDRESS SEWER PMP Z
with tomply wilh s�ch provisions or ihis permil shall 6e r/ —
deemed�evoked. c�" . {, 0� SGI� ni0�3}.- _3 J�J VALIDATION
CONTRAC � BK PG,
UCENSED CONTRACTORS DEClARA710N ��_ y � .
I hereby affirm ihat I om I�censed under prov�sions of Chop�er 9 nDORES � ���=L 3r) V 1 No. G VAWATION
(commencing with Secl�on 7000)of�ivision 3 of Ihe Business and • i��
Professionz Code,and my license is in full force and effect. CrtY (�7�/1✓L�}. � CLASS `� 5 (j(�0 i �^C)
IZJS�3D p_� �'EFt'/ � NO.O / NO.OF CHECK
license N�mber lic.Glass Si0eiE5 / FAMItIES I ONE
Con . . � e f—/[�—j � �ESCRIPTION OF WpRK NEW � S
� I om exempt from the licensing reqviremems os I am a � c���O�rl ��D)T�p� ADD
licensed orchi�ect or o reg�s�eied profess�onol engineer ALTER ❑ DATE � �9 �F '
acting in my professional capacity (Seclion 7051, REPAiR �
Business and Prafessions Code). USE OF " - DEMOL � -FINAL
E%iSTiNG BLD 'L ti BY �p�� - -
Lit.or Reg.No. Dota . aPPt�CAN ,` TEI. c .
'" ` ' OWNER�BUItDER DECLARATION IPqiN, ��''U � � �- Sp^'e�0. �2^ /� {' �� 2�l.S A
I hereby affi�m�hm I am exempt irom the Comroc�ar's license �w,Y-N L 1- n t'L S�, �Q L 1 � �� � � � ���
law for ihe following reason(SeUion 7071.5,Businets and A�DQE55 /U � . �
Profe55ions Code): � �-cocNi �,• •6 1,5 0
� BUiIDING . -
� I, as owner of Ihe prOperly, or my employees with A�D4E55
oges os iheir soie compensolion,will do�he work ond • • •6 1,5 0�
. the shuctore is not imended or ofiered for sale(Secrion � loCntirv �
. 704C,Business and Professions CodeJ. MOVING TEI. �� �2••8 2
� I,as owner of the property,am e.tlustvely comrocting CONtrtn[toR NO. .
- wiih licensed coNrocrors to conslroct the projecl(Sec- qooRF55
tion 7044,Business and Professions Code). -
REQUIRED TOTAI SETBAIX FROM E%ISf.
CONSTRUCTION LENDING AGENCY SEi BACK YARD� HWY pROP.UNE W10TH �
I hereby aff�rm thm there is a constroction lending agency for FRpNI - �
the perlormonce of the work for which ihis permit is issued v.L.
. (Sec.3097,Civ.C.). SIDE � -- -- .. . .
P.L.
Lender's Nome
$ Lender's Address � P.G Fee S Permit Fee J!3• �
W I certify�hal hove read this applimtion and slole thot the Issoo�ce Fee 4'sU '
aabove inior tion is correU.I ogree�o comply wi�h all CoonMy, i�.,es��gm�on Fee .
ordinanc nd Stale lows rclating to b�ildin9 conslrvction,
$ To,a�Fee G i. s�
and her y authori�e represeniarives of this Counry�o eNer
� upon � obove- ntioned V 3 � spec ion purposes. .
a � ���`��G V � ,
(�t: SEE REVERSE fOR EXPLANATORV LANGUAGE
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