HomeMy WebLinkAbout1417A 1418A ' • � WORKERS'COMPENSATION DECLARATION J`7�I
,.i hsraby affirm�hat� hova a certifiw�s of consent�o self APPLICATION FQR BUILDING PERMIT LJ
insure,or a certificote of Workar�Compeneation Insurance,
or a eertified copy�hersof(Sec.380D,tab.C.) �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
PQolicyNo. Company �
Cer;ified copy is hereby furnished. FOR APPLICANT TO FIL�IN qpp�u 'L' O�3I �'. CQLl� �
� Certified copy ia filed with fhe counry building inspec• BUIIDING
�ion depaAmem. pooRess � �� CO�I++Rk �ea� �
Date Applicant CITV w��'i'�d f C� ZIP 9��� IOCAIITY L�(.�
CERTIFICATE OF EXEMPTION FROM WORKERS' �•�&�� �R�`'T / �_ 7�
COMPENSATION INSURANCE � S�ZE Oi�OT V('r Y�C S � NOW ON LOT O Ze r Ck�S ST. �!'J/ll���f C.v/t
(Thls section need not be complated if tha parmi�Is for one ��R �
hundred dollan($100)ar less.) TRAQ BLOGK LOT NO. MqP 9001C .... PAGE PARCEL
T�� use zo pP n�wr
I cerlify Ihat in the pe�fo�mance of the work for which fhis ��R �C��e� �O� �3 �.�p. Z'
permil is issued,I shall not employ any person in any manner e� ��� �
w ae to become aubjec�to�he Workers'Compensoflon Lows. AooREu p Cell ya�a � '� $-�� cowinOnis p
/� U
Uafe � ApPliCanf CITY ��k� �� ZIP %� . �
NOTICE TO APPLICANT: If, after making this Certificafe of a2CHiTEtt OR TEtP DISTRiCT GROU7 ttPE FiRE OCESSED 8Y O
E�emption, you should became�sub�eti to the Worken' ENGI�ER �D x NO.J ��3 O �_, � iOt�E [¢/— - ,� U
Compenamlon provlsions of ihe labor Code,you musf forlh- ���� Q E ie x d n' /✓er�-�w' �+ � g- �� ,3 "bb`"� a,
wltfi comply with s�ch prorieions o� �hie pmmit ehall be i�, STATISTIUL ClA55IFICATIDN APf. CONDO. N
deemed revoked. . . . COMRnROR NO. 2
UCENSED CONTRACTORS DECLARATION p�. CLA55 NO. DVJELL.UNI75 "
1 hereby offirm Ihof i om liCenied und�r provlsions of Chapfer 9 ADDRE53 NO. ��R�P .
(tommentiny wi�h Set�ion 7p00)of Division 3 of the Busineu and ���,
Profesaio�s Code,and my license is in full force and effecr. Ciiv c�,aSS BK � YALIDATION
. 50.FT. NO.OF NO.OF CMKK
License Number Lla Cla� SIZE STORIES FAMIUES � ONE
VAFUATION
CoMraclor Dafe� DESCRIPfIpJ�WORK /f/� ��' p� ❑ S I j ��3/,Q/�� �1 1t 1.7 R
�I am�xamp�under Sec. Fl E t � A�hR � . � #� � � •2 3
8.8P.C,kr fhh reoaon REPAIR ❑ s
Date: E STING BLDG. d YI G DEMOL I 2�2 2� J
Slgnature p'�PRj�T• �� .,�e�r ytSo� ,vo. 3 3�'3 C �iNAt �
OWNER-BUILDER DFCLARAT�ON 1( DAT[ 2 C 2 2 1 5�
1 hmeby affirm that I am eae,npt from th�Conhxtw i License A��� f��tCi�„c�a ��✓�/- �'� � 7j pNAI � 2 2 fi-�f?
law for ihe following roaeon�(Section 7031.5,Businen and
P�ofesaiona Code): AY �� 4�,��
BU1tDING
� I, as owner of the property, or my amployses with nD�RE55 �� � ��9�y� � • • �
wagea a�lhair eole compenaation,will do the work and ' � �(7 2 z�Q
the shueture la no�Intended or offered for wle Seetlon ��m , _
701�,B�sinass ond Profnsions Cod��. ( MOvinlG tE�. •5�6 2 2 0 0 U
� 1,ae owner of the p�operly,am eaclueively contratling CONTRACTOR MO. �!) � 2 2 6-�d
whh Iicenaed comrac�on�o construct ths pro�ect(Ssc- n. Y
AD�RESS
�lon 7041,Busine�s and Profeaslon�Code). ,p�l r�r g
CONSTRURION LENDING AGENCY 5�eACK YAR� Mw�' T�Tp'pRpp I�NE WiDTH C'r ti�
1 here6y affirm thm ihero is o conffrucfion lending agenty for FRONT �J
the performanca of the work for which rhis permit ia iseued p.t. Z� ` z p 0� �!
(Set.3097,Civ.C.). SIDE
P.L.
Lende�'s Name
. ���� S-b IDMA Ref.M
m P.C.Fee f Psrmil Fae i �
Lender's Addreu
� I certity�hot 1 have read this applica�ion and state Ihat thn ^"�'�,B��.�� �vuonce Fea ��•5Q �Dl�nn P/C N
� above information ia correct.I agree fo tanply wilh all Coonly Invntigotion Fee - /-.�f (/ Q
8 ordirwnces and Srole laws rela�ing b building conatrucflon, iorol Pee �v G'z,��� tOMA pe.m.M /�J � �
n nnd he�eby authorize�eprosantatives of this Counry to emer - ----- -�---��- �
upon t bove-man� property for inspec�ion p�rposes.
`,/ /�
�Z-2,6'�E�' SEE REVER3E FOR EXMJlNATORY UN6UAGE �
Iuro of Applicanf or Agen� Dofe \
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