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HomeMy WebLinkAbout1285A (6) � WORKERS'COMPENSATION DECIARATION . � 1 here6y affirm thar I have a certificate of consem to self A �����Q���.� ���...��ii .��A=�_ ����a�4 .__ insura,or a certificate of Workers'Compenwtion Insurance, /"\ /'�\ r� i� fYi r or a certified copy thereof(Sea 3800,Lab.C.) � �� -- - COUNTY OF LOS ANGELES BUILDING AND SAFETY Po�lfcy No. Company BUIL�ING .. Certified topy�s hereby fumished. FOR APPIICANT�TO FILL IN � nooaess�-� ����f���� �C� -l��c� `-Lz+� � Certified copy is filed with the county 6vilding inspec- g���p�ry� p. �1 /� ,7 liOn deparlmenl. ADDRE55 �.� 0 � � ,(�� .� /W✓ .'• ,! LOULITY µ"-u'�ifi"e'�-� NFAREST - Date Applicant QTY ZIP CROSS 5T. CERTIfICATE OF fXEMPTION FROM WORKERS' NO.OF BLDGS. n55E550R COMPENSATION INSURANCE size oF�or � rrow ori�07 nur eooic PnGE vnRCEt (This section need not 6e complered if fhe permit is for one u5E ZOIVE N✓+P hundred dol{ars(5�00}o�less.) iRACT BLOcx toT rio. No. . TEL. SPFCIAL y I cenify rha�in the parformance of the wwk for whicb thiz �wNER a L NO. Od 7/ corromONs � ermil ib iswed,I aholl not em lo an rson in on manner D�STRKT GROUP TypE FIRE PROCESSED BY � P P Y Y PQ Y ADDRE55 CONST. ZONE � U w as to become subject to the Workeri Compensation Laws. /�y J1 —;'T :� � -. +I J _s DatO ApPllcant CITV ZIP STATISTICALClAS51FlUTION APT. CONDO. � ARCHITEC7 OR TFI. V NOTICE TO APP�ICANT: If, aher making ihis Carfifiwfe of ENGINEER NO. C1A55 ND. -�y/ DWEII.UNITS_ w Exemption, you sho�id become subjed.ro the Workera' " Compenwtion provisions of the tobor Code,yo�m�sl forth- p�RE� � � SEWER MAP } wi�h comply with euch provisiona or thia permil sholl�be �� � � deemed revaked. � - CONTRACTOR NO. BK. PG, VALIDATION LICENSED GONTRACTORS DECLARATION ���. I heraby affirm thal I am licensed u�er provisians of Chapter 9 APDRESS NO. VALUATION (canme�cing with Sedirn 70W)of Divisian 3 oF the Business ond LiC. Profeuiona Code,arrc!my license is in ful4 face and effect Ciiv CL455 E � SQ.fT. NO.OF NO.� CHECK LitgMe Num6er LiG Class SIZE S70RIE5 FAMIlIES ONE �W � S COnh«�a p��e OESCRIPTION OF WORN ADD � �1 am exempt under Sec. ntiEe � FINAL �� c�'S f?� 6.6P.C.fw Ihis reason REPAIR � DATE �• • • •2 3 USE OF Pnta: E7(ISTII�K'i BIDG. DEMOL ❑ B�� � ` •�J,�i,('i Q - Si nalure AYPIfCANT + TEL �+- � � c 9 OWNER•Bt11lDER DECLARATION PR�NT ' ��� No. •v u C O�� 1 hereby affirm fhat I am exempt from t6e Controclor's license n� i� ,\;�+ . � / p �,�7—g q Low for�he following reason(Section 7031.5,Bvsinsu and A�DRESS •D:�L Y ir'Y ;� :N ProfeuionaCode): R � ��'�t:�%2 ,�. ❑ BUILDING . � �� '�._ � �%!� I, as owner Of ihe property, or my amployees wifh ADDRE55 wogea as their aole compansotion,will do the work and � ! � ')'� i r the structure is not imendad nr offered for sale(Section ����TY ,�k,�f� I'L ;�L� 7p44,Busineu and Profasaions Code). MOVING TEL. � � I,as owner of the property,nm exclusirely cantmcling NTRAROR NO. with licerned conhociws to construct the projett(Sac- pDORE55 tion 7044,Businass ond Rofeuiona Code). REqUiREO TOTAL SE78AIX FROM EX157. CANSTRUCTION LENOING AGENCY SEf BACK YARD HWV p�p ��N WIDTH I here6y affirm that there is a constrvdian landing agency for FROM � the perfamanca of Ihe work for which this permit is issued P.L. �Set.3097,Civ.C.). SIDE P.l. Lende�s Name $ P.C.Fee 5 Permif Fee Lender's Address . � I certiiy that I hove read this application and ntata that ihe - � luuante Fee g above informalion is mrtecl.I agree to comply with all County Investiqorio�Fee �f ordinances ond Stare lawa relating to building construcHon, Toml Fee 8 und hereby aulhaize represenfatives of this County to enfer � vpon the abave•mentioned property for inspection purposes. : - �- SEF YEVERSF FOR E%RANATOItY UNGUAGE � Signatur�oP App�iwnt ar Agent Doro � � ��� . 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