HomeMy WebLinkAbout0827A 3285A (8) WORKERS'COMPENSATION DECLARATION � �
I hereby offirm thal I have a certd�Fata of consent lo self � �
insure,o�acernfimieofWorkers'Compensa�ionlnsurance, APPLICATI�[V FOR �IJtLDIlV�► PE���T �
or a cerlified wpy thereof(Sec.3800,lob.C.) � � -�
COUNTY OF LOS ANGELES BUILDING/1ND S FETY
Poli�yNo. Company �
� Certified copy is haraby lurnished. FOR APPUCANT TO F1LL IN q�pp�ZE� � �� ,'
� Cer�ified copy is filed with the munty buildinq inspac• gUu�iNG �� y
Ilon depatiment. AD�RE55 V ij.t.Q�
Oa�e Applicant CITV Zi� �OCidi7Y
' ' CER7IFICATE OF EXEMPTION FROM WORKERS' � � NO.OF BtOGS. raFAkES� /) .
� �COMPENSATION INSURANCE �� � . SiZE OF iOT NOw oN iOT � ` CRO'�s St Z,Q�q
(ihis�ection nsed no�be compleled il tha permit Is for one iRnCT�T 3 I/ BLOCK�JW A���R
hundred dollars(f100)or lesi.) . �Ot NO. µqp gp�* PAGE PARCEL
TEL. USE ZONE M�
I ceni(y Ihoi in the por(o�mance of the work for which this OWNER�( NO. �yp, OC '� �}
permit Is ies�ed,I shall not employ any person in any manner qDoaE55 S�FCIAL n-
io as�0 6ecome su6jact lo Ihe Workers'Compensolion laws. n_ CON�ITIONS O
. 1• .. ' .. CIiY '7� ZIP �. CU!-' Z Z�� �
Date ' APPlicanl � ARCHIIECi OR TEL. 7 O
'�TICE TO APPUCANT: li, a1�er making Ihis Certificole of NGINEER NO. DISTRICT GROU7 TYpE FiRE PROCESSED 6Y
option, you ahould become sub�ect �o the Workers' . �^/� ¢/'J cOr�Si.,'/ Zo�E G
� ..,Qsnsa�ion provisiont of Ihe lnbor Code,you musl forlh- q0�RE55 l�l, - cJ /� �/ � d- '
with comply with.auch pravisions qr ihis permit shall be . � w
d�smed twokad. I�` TE�� STnt'�S1iCAl CtAS iFl tiON qvT. [ON00. 2
( � CONTRACfOR *W � NO
UCENSEO CONTRACTORS DECIARATION � �i�, QnSS N0. DWEu.UNiTS '
1 he�eby otiirm�ha�I pm licensed under provision�of Chopter 9 AODRE55 ✓�lL, NO.
(commencing with Sec�ion 7000)of Division 9 0(�he 6usiness and . �i� SEwce huv �
%ofessions Code,ond my license is in full{orca and effeU. aiv ftnSS �—� � BK � � ' VAl10AT10N
� ' SO,fT. � �NO.OF NO.OF CHECK
LiGense Numbet Uc.C�a55. b_ SRE STORIES FAMIIIES ONE ,
'� ' � � ' � � VALUATION
COnlro[lor W���''fD/J CU/ Ddla DE9CRIPTIONOFWORK NEW � � �
❑I am eRempt under Sec. A� � ; � ��8 2 7�
.. ' - ALTEN �
� B.6P.C.for thi�rensan • REPAia s ' a• • • •2 3
oaea: use oF o�Ma 1 • 1 9 1,2 5.
exisnNc e�oc
$ignolufe � APPLPRINrTT� (.(.Z NO V-� FINAL • • 1 9 1.2 5 U
OWNER-BUIIDER DECLARATION .GATE .
' I h�rr6y offirm ihal I om eaempt Irom�ha Contractor's liconsa qpDRE55 I 2 O S'S 6
Law for the following reason��Seclion 7031.5, Business and FtNAI
Profenlons Code)r - .. . `. . . gy - . . •
r I, as owner of�he proparty, or my employees wiih �qooR[ss G
woges os Ihair sole companaalion,will do the work and �-� � - �s �nn L��f..:� , h 3 7 R 5 A
Ihe struclure is no�iniended or oFfarad for sole(Settion ���ITY
� 7W�,Business and Pro4essions Code). � MOVING ,E�. �jy) g33�,f� ��. � . � � � �
� I,as owner o(tha propeny,am exclusivaly contmcting CONTRACtOR NO. , .
with licensed conirpcbrs lo cOnslrucf iha project(Sec- � ADORESS � � '��',�1 5�
tion 704�,Business and Professions Coda).
CONSTRUCTION LENDING AGENCY RCOwRe� YaRO HwY «�A��1eA � - � • •�J Ei S O 2�
SET BAIX raov.ur�e WIOTH
I hereby al(irm thor there is a construclion lending oganty(or iROM
�he performonce of�he work for which Ihia permil ia iseued P.l �c�.,� � —8 7
(Sec.3097.Civ.C.). ���t� � /J SIDE . ' .
� (/1�W'YIW�t�.K�f' P.L. .
Lendar's Nama
Z.��= IDMARef.N �
� LendePs Address P.C.fee t J Parmit Fee '
C 1 certify Ihat 1 Fwva read ihi:applicalion and state tha��ha . bmonro Fee �V� iUMA P/C M �. . .� ,
{ p6ove informotion is corrxt.1 agrae to comply with oll County Invesngo�ion fee �J �/[7
g ordmancea and State laws ralaiing to buildmg ronst�uction, Toiol Fee `3��'� ID�M Prm.Y � ��
�and heroby auihorixe representa�ires of�his County�o enter �
� u Ihe aFrove•mentiona roparly for inspeclion purposas.
J SFE REVFRfE FO�FX►LANATOIIY LANGUAGE
. �n�...¢�. O_/�� oZ—�
� S�yrwwn ol AppLmn�o.Apen� � - pote . . _ . . . G�