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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