HomeMy WebLinkAbout1272A 1897A �Y \
WORKERS'COMPENSATION DECLARATION ' �n
I herehy affirm that I have a cerrificale af consenl to salf - f �S
,�,�.�,oraeertificaieo(Warkers'Compensation,�=��a�«, APPLIC.AT�ON FOR BUILDING PERMIT
or a certified topy thereof(Sec.3800,Lab.C.� � i '
��p 5 COUNTY OF LOS ANGELES BUILDING AND SAFETY�� A
Poli o. ompany_ ��1 �..���/� �
� CerriFled copy is hereby fumtshed. FOR APPLICANj TO FIIL IN ADDRESS � .7 Q ,�. �-C .�/,�� -
� Certitied copy is filed with rhe covnty building inspec- BUiIDwG �
tion deporfinent. � ADDRE55 � �j /Iti/hp ( IOCAUTY »+�.Isc�L. �
1 NEAREST
Dale •�Z� -� pplicant Cltt D ZIP CROSS ST,
CERTIF�CATE OF EXEMPTI FROM WORKERS' � NO.OF BLOGS. ASSESSOR
� COMPENSATION SURANCE SIZE OF lOT NOW ON LOT AMP BOOK PAGE PARCFL
� (This setlion need not be compleled ff fhe permlt Is for one USE ZONE MAF �
hundred dollors(5100)or less.) TRACT BLOGK tOT NO. NO. � �`>� ��
OWNER � S� TEt. �-� SPECIAL
• I tertify thal fn Ihe pe�formonca of the work for which lhis NO. �ONDITIONS 6}.
p2lmit ii i51u@d,I shall not employ any penon In any manner � 4 DiSieKT GROUP TYPE FIRE PR fSSFD BV �
so as lo betome subject to the Workers'CompensoNon laws. AODRE55 e� \ �LFi ��� CONST. ZONF V
/O ' C
Dafa � ..' � APPIitOnf . .. .� . . . CIN ��� ZIP.. STATISTICAI ClP.SSIFI TION AVT. CONOp. �F
NOTICE TO APP(ICANT: If, after making this Certificole'af � bRCHITE OR •�.:7 l,� � - ... . .. � J� V
�Exempfion, �yoo shoold 6ecome subjetl��lo fhe Worker5' - ENGINEER��� � �.� NO. �. ��CLASSNO.,�sLDWELL UNITS � ��i
Compensotion provisions of the Lobor Coda,you mvsl forth- noDaE55��� �(,pt SEWER MAP '�
wllh camply wi�h such provisions er this permit shcll bo � �TE� � � ?
deemed�evOked. � CONTRACTOR �- NO. . BK. PG, VALIDATION
� LICENSED CONTRACTORS DECLARATION C �
� I hereby affirm thot I am licensed under provisions of Chopter 9 ADDeE55 j O. Z - VALUATION
(mmmenting with Section 7000)of Division 3 of the Business and ,� LIC. �� 2 7�2 A
Professions Code,and my license is in full force and effect. ci7Y '�� CtA55 C' E .8j� •��--- �
�/ /��� Sq.Fi. Np.pf NO.OF CHEIX , it• • • •2�J
Licensa Nom6er_j�^ ,l _Lit.dass C;4S SIZE STORIES PAMILIES ONE �
�q-..{/ u.�. � � DESCRIPTION OF WORK NEV'! S� � � �2 S.O O
Con}raCto�w+'� 1�� Date ��� �N � .��, � A�� � � •�• •2.rl d Q U
❑I am ezempt�nder Sec. � �
B.&P.C.for this reason ( S RE ARQ� � DA EL � f -0�.2 7—8 4
USEOF ��.C.r.t ?b�o/► EMOL ❑ gY I4'lL�.lae���
DO1e' ExiSnNG BIDG FINAL � � �
, Signafura � Ava M .J u� NO. d � ...
- OWNER-BUILDER DECLARATION . -
I here6y nf(irm thar I am exempt from the Conrroctorb Ltcensa ADDRFSS�t S �Ir 1� A � ► �
law for ihe following reason(Setlion 7031.5,Business and --' � � �
Professions Code): . . . veESeNt
❑ BUILDING , �
I,as owner of rhe p�operry, or�my amployees with aooaE55
wages as fheir sole compensa�ion,will do tha work and � . , �
.. tha slrutlure is not infended or offered for svla(Section ��`��TY
7044,Business and Professions Code). MOVING TEL. '
� 1,as owner of Iha ro erf am e�clusivel contratfin C NTRACfOR NO. f�
P P v, r s 189,7A -
�. with licensed contracton to consnuU the project(Sec- aoDRe55 �. . . . . � �
tian 7044,Business and Professfons Code). . � , �
• � REOUIRED TOTAL SETBACK FROM E%IST,
CONSTRUCTION LEN�ING AGENCY SET BACK �ARD HwV PROP.LINE wioiH I • •3 b 7 5
I hereby offirm�hot there ie a mnsrrvc�ion lending ogency for FgpNi �
�he parformonca of the work for whith thie permit is issued r.t. .• • ��(z 7 5�
t5ec.3097.Civ.C.). SIDE .
v.`. 0305-84
Lander's Name � - u) / �
P.C.Fea S �`�v Permit Fee �S�•��
Lander's Address � -
I certif that I haJe read this a lication and stote Ihat the � � � ��O• .�U � - - - � �
Y PP � Issuonce Fee
above information is carrect.I agree fo comply wilh all Counry Inveseiqot�on Fee
o�dinances and State laws re�ating fo b�ilding consrrucfion, Totol Fee .3C• �.�� �
ond hereby authorfza represanratives of thls Counry�o enter � , ,
opon 1he obova•meM"oned opert (or Inspection parposes. � - � � - � � �
� Z �$ � SEE REVERSE FOR EXPLANATORY LANGUAGE �
SignaNr ol App icant or Agen Dme � . .��
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