HomeMy WebLinkAbout0896A (4) WORKERS'COMPENSAiION DECLARATION . � ,
� �a�abY affirm Iho�I have a�e.,;f;�a,a of.consent�0 9a�f qpp��CAT10N FOR BUiLDIfVG PERMIT
insure,or a cer�ificate of Workers'Compenstion Insvrance,or
o ce�r�fied copy the�eof(Sec.3800,�a6.C.) COUNTY OF LOS ANGELES HUILDING AND SAFETY �
Policy No. Company BUItDING `
� Cerlified copy is hereby fumished. ` ! FOR APPLICANT TO FILL IN o�,�� ���L/ /�
aADDRE55
Certifiad copy is filed with the counry 6uilding inspec- /� BNtDING n �A• _1 �/ -7�
tion departinent. / A�ORE55 �y� �• ld • � (j�. LOCALITV N�/
��^� NEARE57 �Q� '
Date ApplicpM� � CITY �/l./ ZIP � CROSS ST.
CERTIFICATE OP EXEMPTION FROM WORKERS' NO.OF BLOGS. ASSESSOR .
COMPENSATION INSURANCE SIZE OF LOT NOW ON LpT MAP BOOK PAGE VARCEL
(This setlion need not be campleted if the permit is for one USE ZONE MAP �j
hundred dollars($100)or less.) TRACT BIOCK LOT NO. NO. � y
TEL SPECIAI y
.I certify that in the performance af rhe work for which this � OWNER 1f1_R/ (a NO. �1• e� CONDiTiONS Q �
1 permit is issued,I shall not employ any person in any manner � C � n_/ DISTRICT G UP TVPE FIRE P E�eY �J
so as lo become subject to the Workers'Compensation Laws. ADDRESS D �S�G1 CON57. ZONE
CITY � (� C � Z�P c,Z � a -z l` 3 0
Date Applicpnt STATISTICAL CLASSIF CATION APT. CONDO. �J
NOTKE TO APPLICANT: If, afier making this Cerfifimle of � ARCH�TECT O 7EL 7/ W
Exemption, you should become subject fo the Workeri ENGINEER �er S4,��`ir. No. -� t�� Cta55 n10. � DWELL.UNITS_ d.
N
Compensafion provisions of the Labor Code,you must-forth- qDDRESS �('(�,f� n SEWEI2 Mna ?
ith comply wilh soch provisions or this permit shall be TEL.
daemedrevoked. CONTRACTOR- OC'�No. BK. PG, VAIIDAiION
L�CENSED CONTRACiORS DECLARAiION {�
i I hereby affirm fiat I am�icensed unde�provisians of Chap�er 9 ADORE55 WN�� �i)�\ NO.
VALUATION .
(commencing wiih Seciion 7000)of Division 3 of fhe Business ond • tK. � ^ ��F
Professions Code,ond my license is in tul�forte ond effe[t � Giv ' CtA55 E �aV �e�
5�.Fi. NO.OF NO.�F CHECK
LiCense Number LiC.Class SIZE STORIES FAMILIES ONE r�•• •• • 1
S
Contracto� Date DESCRIWIONOF WORK N� ❑ �� . ��� F(�
� I am exempi from fhe licensing reqoiremenfs as I om a N � M � ADD � � � a �_,� _�n; �
licensed archiiect or a registered professionol engineer . • nt7ER FlNAI q p . �
acfing in my professiona� capacity (Section �051, ./ TL.e �G D�5" REPAIft � OATE .} � /�pr D Q�'���i ..
Busineas ond Professions Code). USE OF �Ma � fINAL
E7(ISTING BLDG. , BY � y� .
�Lic.or Reg.No. Date APPLIGANT� TEL /r-r,C ��
OWNER-BUILDER DECLARATION PRINT) 71LWi/J A8 NO. rau-�� fJ.C 8���'
I herehy affirm ihat I am eaempl from Ihe Coniractor's Litense �G��c— t/l_ R �/.
Law for the following raoson(Section 7031.5,Business and /+�DRE55 7 W �27 01 �/�/ar/
Profassians Code): , pgESENi �
8V It�ING
��"1, os owner of Ihe property, or my employees with pooRE55 .
wages as their sole compensatian,will do?he work and
� the structure is nm imended or offered for sole�Section tOCnliiv .
7044,Business and Professions Code). MpwNG iei.
� I,as awner of tha property,am exclusively coniracting CONTRAC70R NO.
with licensed cantrociors io construct the project(Sec- pDoaE55
tion 7044,Business ond Profeuions Code). �
- REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWV p{tpp.��NE ,WIDTH
�hareby affirm that�here is a construction lending ogency for FRON7
�he performance of the work for which Ihis permit is issued P.L �
(Sec.3097,Civ.C.). - SIDE '.
. . .. P.l. . .
Lender s Name . -
Lendei 5 Address P���Fee 5 ���-� Permli Fee , O
I rertify rhat I have read this applico�ion and state tha�rhe isso ce F�e •'��
abov infarmation is mrrect,I agree Io comply wilh a�l County Investigotion Fee �n � ��
ordin nces and Sote lows rela�ing to building construction, ioial Fee
ond er by au�horize representmives of this Counry to enrer �_
up 1 obove-mentione roperly for inspection purposes.
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