HomeMy WebLinkAbout1206A WORKERS COMPENSATION DECLARATION � - �
I hereby affirm �ha, � h��e a cerfifitote ar�on5e��,o self � App��CATION FOR:: BUILDING PERMIT
insure,or a certifimte of Workers"Compenstion Insurance,or
a ce�rifi�d� �y r e e,of_I�Se)_3epo,�ab. .) r.j; COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. . �� dCompany C+ ' [l�/�""�
� BUILUIN(G ' t
Certified copy is hereby furnished. FOR APPLICANT TO fILL IN noosess ��r d'v�ies^! C•i /t``�°
Certified wpy is filed wiih ihe cR unty building inspec- BUILDWG O✓
uo�dopa�rme��r. W,.,,,{, nooRess � �3 � jCl� Cr! �L �ocnurv �4!'W7�!✓/ C.•�
�n��-- f�t��������
Date�_.A licanf �S.ra�+T'^�u'S��ih �a CITY �� ) �+. NEAREST
pp -�r,'i� r L C� zIP � CROS55T. 4�y G
� CERiIFlCATE OF EXEMPTION FI�OM WORKERS' NO.OF BLDGS. A55ESSOR
COMPENSATION INSURANCE SIZE OF LOi NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permif is for one USE 7pNE MAP 'r � �� �
hu�d�ed dolla�s($lDo)o�less.) . rkncr stocK �or No. rva. ,�
TEL. n� SPECIAL �
I certify thaf in ihe performnnce of ihe work for which fhis ���'�'NhR� /��P`' NO. ^ CONDI7lON5 � � �
permit is issued,I shall not employ ony person in any manner - / / ) UISTRIC7 GROU4' TYPE FlRE PROCESSED BY �
sa ns to hecom2 subject to ihe Workers'Compensotion Laws. ADDRE55 ((;oRlj�n�5& � -*�y�/G 1� CONSi. ZONe �,�n ('\ . �
/ �`��l �
Dote Applicant � CITY f T19�yVJ ` CY 7�P SIATISTICALCIA551FI ATION � APT. CONDO. �
ARCHITECi OR T[L.
. NOTICE TO APPLICANT: If, after making ihis Certificate of �� � �
Exemption, you should beconie subjecl to �he Workers' ENGWE[R NO. CIASS NO. DwFLL.UNIiS_ p,
Compensation provisions of the Labor Code,yau must torth� `�
wilh comply with such provisions or this permil sholl be AnoRE55 ` Sf.wFRMnP �
deemed reVoked. l �E`,�J� �� 6K. PG, VALIDATION
CONTRAC7'U I '{A NO.
LICENSED CONiRACTORS DECLARATION y - iiC. ty 2
I hereby nffirm�hnt I nm licensed under provisions of Chapter 9 ADDRCSS �� ��/ `L NO. 0����e VALUATION
(commencinc�with Seclion 7(%�)of Divisiori 3 of ihe Business ond w�l LIC. /' r (�q�,
Professions Code,and my license is in full torm and ette<t. U7Y �' ��'•[��'j C1A55 L��. � J� V C� -
"'� � Sq.FT. NO OF NO OF CI-IECK
�12Q6A
License Number � '��� Lic.Class� SIZE STORI(S FAMILIES ONE ��•.�,• ��3
� �� DESCRIPTIpN OF WORK Pt9�'. P PC. ;
NEW g
con��a�m, C�vl►9a 5','?�Yi r o�f� Gr �-. 7t�'C, nvo f • 0 1 3,6 0
� I am exempt from-ihe licensinc�requirements as I am o )�-
licensed archilect or a regisrered professional engineer ALTER � FINAI P d a:1 3,6 p c=.i
acting in my professional c pacity (Section 7051, � DATE �
8usiness and Professions Code). USE Of REPAIR
. EXISiING BLDG. �A DEMOL � FINAL 0 7.0-5—8 2
Llc.or Re No.�__. Date APPLICANT TFt. p y BY
9 OWNER-BUILDER DECLARATION � PRWI 1 � j��1(' NO. J�=(��1
I hereby affinn t4iai I am ezempt from ihe Coniractor's Licensa /" p,�rA. [q_' ��J
Law for the followinq reason(Se.dion 7031.5, Business and ADDRESS - (7 ^"CIICCi �[����[7%+ �
Professions Code): � PRESENT
6UILDING
� 1, as owner ol ihe property, or my employees wifh ADDRE55. �.,�
wages as their sole compensation,will do Ihe work and � ',�� ,
Ihe s .... - - --;{e�ed for soie(Secrion ���"�I'' � �� �
r�������.e,�„cf;nten.,�d� � '
7044,8usiness nnd Professions Codo). MOVWG � . fEL ,7 "'& �
� I,as owner of�he properly,am exdusively contracting CONTRACTOR NO. �s�-/J •a�
with licensed contracfors lo conslruU Ihe project(Seo ���� .
. tion 704q 6usiness ond Professions Code�. ADDRE55
RF.QUIRED� TniA�SF.IBACKFRnM EXIST. �
CONSTRUCTION LENDING AGENCY SET BACK �ARD HWY PR[�V.LNE W�D1H
I hereby ufFirm thoh Ihere is a cons�ruction lendinq agency for FRONI ,
the perfannance of rhe work for which ihis permit is isaued p i.
(Sec.3(�7.Civ.C.). . SipE -
i�.�.
Lender's Name �
Lender's Address P.C.Fee 5 �� Pcrmif Fee
I certify ihot I have rend this applimtion and sta�e ihat ihe iss� ce Fee
above informaiion is mrred.I agree to comply wiih oll Counly Invesiigoticn Fee �
ordinances nnd State lows relatinq to buildiny conslruction, � Toiol Fee -
and hereby outhori�e representatives of fhis Co�nly to enter
upo the ab�e tion{p d pwperry for inspection purposes.
� ��.�'�JC.[�/; :J Q'�� J.- SEE REVEkSE FOR EXPtANATORY LANGUAGE
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