HomeMy WebLinkAbout0827A 1458A (6) 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
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