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HomeMy WebLinkAbout0827A 1458A WORKERS'COMPENSATION DECLARATION � •� 1 hereby affirm thot I hove a tertificote of�o�,e�r�o se�F � � qpp��CATION ��FOR BUILDI NG PERMIT insura,or a certifitate of Workers'Campensation Insurance, . � or o cmtified copy theraof Sea 3800 Lob.C.) �� � � � � � � � h � �-+ /t �a COUNTY OF LOS ANGELES � BUILDING AND SAFETY Poli No. ompany�_�Kht��� P� � Certified copy�s here6y furnished. FOR APPLICANT TO FILL IN - noo ess 1 � � � � Certifiad copy is(iled with the tounty bullding Inspec- BUII�iNG � 0 � /� � � tion department. . . ADDRESS � V LOULITY�- • NEAREST Dale Applitant CITV ' ZIP CROSS ST. �N� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF l0T NOW ON�Oi MAP BOOK PAGE PARCEL �This section need not be comple�ed if the permit is for ona USE ZONE �P hVndred dollan($100)or less.) TRACT BLOCK LOT NO. MO. TEL el�. SPECIAI a I cer��f �ha�tn ihe erformance oi�he work for which�his OWNE2 DU No.11a�� O CON�ITIONS Y P �ISTRICT GROUP IYPE FIRE PROCESSE�BY d permit is issued,I shall not employ any person in any manner "� � ����'�-� �- �pNST Z E � V AODRESS Z�1 so as to become subject to Iha Worken'Compensotion Laws. /��! ,O � O � � . Cltt ZIP....'7�/ a .._,.� STATISTICAL CV+SSIFICATION � APT. CONDO. F�- Da�e Applfcant ARCHITEG OR TEL. " � �V NOTICE TO APPLICANT: If, after making thls Certiiitate of Er7GwEER f/ � N Na.���7��� MSS NO.�DWE0.:UN�75 �L �Ezemp�ton, you should become subject to Iha Workers' �' y Compen:arion provisions of the labor Code,you musl farth- ADDRE55 �. 3-d!� SEWER MWP with comply with such provisions or �his permit shall be ,K� � VALIDATION � r deemed revoked. � COMRACTOR ^� . O BK' �'• � . LICENSED CONTRACTORS DECIARATION � Li . . I heraby aHirm thot I am licensed under provisions of Chapter 9 nDDRE55 • NO. VALUATION � . ! (commencing with Sedion 7000)of Division 3 of the Business and � ���' � E C�� . f Professions Code,and my license is in full force and effect. Ci7Y �IA55 d. . 1 S(�.FT. N O NO.OF CMECK - 1 0 8 2 7 A • � LicenseNumber ������ Lie.Closs� SIZE � RIES FAMIUES ONE � , . � � �ESCRIPiION OF WORK W ❑ a . #• •�• •2 3 Contmctor Data - . ._.. �p ❑ . I • •2�O O . . �I om exempt under Sec. ALTER ❑ _ FINAL r/ . B.BP.C.for this recson Reania -❑ �DATE �o7I�fI'J •�• •25.00c=i � Dafe: USE OF . DFMOL ❑ � FINA - . . O��O 3"8 4 E%ISTINCi BIDG. il , oY �` �]�.�� ' Signature APPLICANT TEL. _ _. . . . ... OWNER•BUILDER DECLARATION ' PRiNT If "� NO. O I hereby affirm that I am exempt from tha Contractor's Ucensa � � _ _ . _ . , . _ Law for the following reason(Secfion 7031.5,Business ond ADDRE55 � Professlons Code): PaE ENT �� � � ❑ euimwc � I, a�owner af the property,or my employees with ADDRESS wages as their sole tompensation,will do ihe work and . the slrudore I5 not fntended or offered for sole(Sec�ion LOCnUTY . . 7044,Business and Professions Code). . MOviNc ��• �1 4 S,8 A � � I,es owner of the property,am exdusively canrrdcring ContTzaROR No. ,_ -� wi�h li[en5e(J coniraCtors to Co�strucl the projeU(Sec- AD�RE55 #• •� � ��1 � lion 7044,Business and Professions Coda). -� - � -- - �- � � - ' � � REQUIftED TOTAI SETBAGK FROM EXI57. � CONSTRUCTION LENDING AGENCY � � SET BACK YARD HWV PROP.LINE wiDTH . I'� �`3 `5 I hereby affirm 1ha�thare is a mnstruc�ion lending ageney for prtoNi - -� - ' - , ��� �� � •�a •3 6 7 5� tha performonce of the work for which this permit is issued P.t. , . t5ec.3097,Ci�.�.1 P��E . .. _ . ._ .. _ .___ . . . . 0 2 0 9-8 4 Lender's Name � . � � n^ . . . . .. .. ._.. _ .... . Lender'e Addiess v.C.Fea S ��1W Perma Fee ��• .�✓`� � 1 tertify ihat I have�eod ihis applitation ond sroie thot tha � � Issvance Fee�� `SD obova informatlon is correcl.I ag�ee to tomply wBh all County invesugat�on Fee .. _. . .. . . . .. . . . � o�dinances and SWie IawS releting to building cons}ruction, � 7orol Fee .��• 7� and hereby authorixe representatives of this County to enter ; an tha obove-mentioned property for inspection porposes. � - � � �--� " "- �� �� � � � � SEE REVERSE FOR E%PLANATORY LANGUAGE Sign ur olApplicant ni po�e � . .. . .. �. .. . _ � . . . . �s ...._ _...r-- _. z -+ - - o � � T �_ _o __ - -�� - v Gl _-}.�._ ' 'a r Cl'O • O � � Q .Q.. p � ' , . � ��, � D.�,17 . 3� O p.. p �. : T � � .n ^ O 3 Q (1. � r m ,n U+ p �O� L 7c.� Q� n;A � '..�i �., � � � � ^ 1�`� 1 � O � ; Q O C O . �.: P' � ' n• � n : z� 1 � m_T (1 S O cp -[T .�3 O'-. ' t� - �,-- ' Q O'. � �: L . 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