HomeMy WebLinkAbout1816A 1817A n,r ■ ■ � v �
WORKERS'COMPENSATION DECLARATION . ���������
I here6y oitirm thol I have a cenificote oF consent�o self �p���CA�t�N FQ� � �
msure,o�o tenificafe of Workers'Compensalion Insurance,
o�a mrtiYed copy ihe�eof�Sec.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Compony
� Cer�if�ed mpy�s hereby 4umished. FOR APPLICANT TO FILL IN su����raG
nooRess
� � Cerfiffed wpy is filed wlrh the county b��lding inspec- BUIIOING -
liondepor7meM. ADDRESS � �, �1}y{p
Date ApplicoM � C�7Y L T ZIP 7 q� �p�q��Ty
CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BlDGS. f�&AREST
COMPENSATION INSURANCE SIZE OF lOT �vOW ON tOT CRO55 ST.
(This section nead not be completed if tha permil i�far ane ASSESSOR"
TFACT BIOCK lOT NO.
hundred dollars(5100)or less.� . �80dc PAGE PARCEL
� 7Et.� Z, U5E ZONE M1AP
I ceni/y�ha�in ihe per/ormonce oi ihe work for which this � OwNER � � ) (_ �
permit is issued,I shall nol employ any person in any monner v�� SPECIAL � t+ , O�
so as to bemme Subje[t to fhe Workers'Compensatipn lows. ADDRE55 ' CONDITIONS J (�
Date Applitant CITY ZIP , . �
NOTICf TO APPLICAN7: If, after.making ihis Certificate of ARCHITECf OR TEL DiSTRI GROU PE flR PROCESSED BV �
Exemption, you should become su6ject to the Workers' A GIMEER NO. � CON57� ZONE � a
Compenso�ion provisione of Ihe Labor Code,you must forth-
wilh comply with s�ch provisions or Ihis permif shall be � )� T[�, STATISTIGI C SIfICATlO APT. CO�O. �
deemed revoked. cOWiRnCT /�J —
LICENSED CONTRACTORS DECIARATION �� . �QASS NO.� tL UNITS �
I hereby affirm thot I am licensed under provisions of Chop�er 9 ADORE55 (9 �.
(rnmmenci,g wiih Section 70DD)of D�viaion 3 of rhe Bus�ness ond ��� SEWER MAP
Rofeuions Code,and my license is in f�il force ond effe[t. CI7Y CLA55 YALIDATION
SQ.Ff. NO.OF I.b.OF �HECK 8K. PG.
Liceme Num6er Li�.Class SIZ OR1E5 FAMIilES ONE �
. �ESCRIP71pN pF WpRK � ~Q� NEW V�UAT�ON �
Conhacror Dale ADD = �� � : � ;' � (�.n
❑I am eaempf ondar Sec. ��� ❑ �_ _ . Y �__'_,
8.8P.C.fo�this roafpn REPAIR � s ^ .
Dare: use oc I = = �.` ;..
existir�e�. oerna ❑
Signalure APP�ICANT TEL. flNAI • rs ° -.. �� .,-..
OWNER-BUILDER DECLARATION ��NT � ' � � • '''��r `��- 1 pA7��,� �
I h reby affirm rhat 1 am exempr from ihe Controcror's License �_. � !;--?-�
La for the following reawn(Sec�ion 7031.5, Business and ADORE55 FIN �
fessioas Codel' aRe Nr eX�.. . -�'� n �,�l�.
eunoiric • 1
I, oa owner of the property, or my employees wifh ADpRE55 ' �
wages as Iheir so�e compensa�ion,will do�he work ond � , " � � °
the struc�ure ia nor inrended or offered for sale�Settion tOCAtiTY
70I4,Businees and Professions Code). nnpwn� � re�. ' n �_...�;
� I,as owner of the property,om exclusively conMacling CONTRACTpR NO. � -
with licansed controcrors to conatruc�ihe projatl(Sec- A�R� ' . e o ?,!,j-,'::
lion 7W4,Business ond Profcnsions Code). ��
REQUIRED IOTAI SETBAIX FR � ('�� '� i�
CONSTRUCTION IENDiNG AGENCY �ARD �iwv - - -�" �
SET BAGK PROP.tINE WIDiFi
I here6y affirm fhot thme is a consh�ction lending ogency for FROM
�ha performance of the work for which this permit is issuad p.�, �
(Sec.3097,Civ.G.). s�oe
P.t.
lender's Name '
IDMA Ref.M
Lender's AddreSs P.C.fea S / Pormit Fee D
I certify thal I hnve read this appiicatian and sfata that the lu�once Fea � LDMA P/C k
abore informotion is correcl.1 agee to comply with oll County lnreatigotion Fee
ardinances and Stale lavn relating to building mnstruction, toro�p� �Dµq perm.�
and heraby authorize representotives of ihis Co�nry�o enter �
� upo�1 above-mentioned property 4or inspettio purposes.
♦
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lure of p ont en po�s
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