HomeMy WebLinkAbout1053A 1543A (9) WORKER$'COMPENSATION DECLARATION I V Y��� �\�`�( � �
I he�eby af(irm thot I have a cerfificate of�o�se�„e se�f � APPLICATION �FOR BUILDING- PERMIT
insure,or a certifico�e of Workers'Compensation Insurance, i �
or a certified copy thereof(Set.3800,Lob.C.) COUNTY OF LO$ANGELES BUILDING AND SAFETY
PolicyNo. Comp�ny - BWLDING
� Certified copy Is hereby f�rnished. FOR APPLICANT•TO FILL IN ADDRESS 7
� Certified topy Is fited wilh tha monry bollding inspec- BUiL�ING - ^-
tion departmenl. . . ADDRESS ��.. ��• LOCALITV l�� �J6.1C
. � NEAREST ,
Dota Applicant „ Cltt �4..v�^•O ZIP CROSSST.
� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF etDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF l0T NOw ON�OT M.4P BOOK PAGE PARCEL
(This setlion need not be comple�ed if�ha permit is for one u5E ZONe /�+v+P _!
hundred dollars(SI00)or Iess.J TRAR 8�0[K LOT NO. NO. III�" �+�' /
\ � TEL SPECIAL 0.
�certif that in the performance of tha work for which this OWNER }(� NO. �� CONDITIONS
y DISTRICT GROUP TYPE FIRE PROCESSED BY O
permil is issued,I shvll not employ any person in any manner ' CONST. 20NE�
. so as to become subject lo the Workers'Ca ens6tion Laws. a��RESS L. � � � �
/ � �
CITY Z�P
Daie - APPII[an� ' l � '. � . � , .. . STATISTICAlCLlSSIFICATION , _ - APT. CONDO. O
NOTICE TO APPLIGINT: If, ofrer� king thls Cefti{i[a1B'OI � ARCHITECT OR'� -�- \ ` ' �TE�1 � ��' - � � W
Exemption, you shouid-become� �ecl�do the Worken' � ENGMEER':.�'C ' � �OV�'. ��- ��NO. �•OZ. � :�L4$5 NO. `�a�- DWEII.LNITS_
a
Compensation provisions of the Labor Code,you must forth- �, ADDRE55��-\ � ' - �� \ � SEwER MAP �
with comply with such provisions or this permit sholl be ._. E�, � =
deemed revoked. � � � tONTanCTOR ' ,r.t�1 C� -1. � NO. � � � BK•� --�. � VAIIDATION
LICENSED CONTRACTORS DECtARATION � uC.
I hereby affirm that I am licensed under pravisioni oi Chapter 9 t AD�RE55 NO. VAWATION ' .
(commendng with Seclion 7000)of Divislon 3 of the 8usiness ond LIC. � �.
Professions Code,and my license is in foll force and effect. . QTV C1A55 s Q� S . �1 0 5 3 A .
' - - � SO.FT, NO.OF NO.OF CHECK . '
Licensa Number� � Lit.Class ' S12E STORIES FAMILIES ONE �_� � • •2.3
� DESCRIPTION OF WORK N� ❑ 5 I • � � I�9�1
Contractar Dala ADD � �
�i am ezempi under Set. , ALTER � FINAL � �•.• � � �'9 4�
�����i.� DATE -
B.BP.C.for this reason � REPAIR ❑ � � �.� 7�8 4� -
Da1e: i USE OF `(� p��� � FINAL � � -
� � E%ISTING BLDG. �F�l'iL ���' By F� �
� Signature �-`1 . ' APPIICANT TEL.-��L\ . .
O N R•BUILDER DECLARATION . �, PRiM NO. -pZ �`�;� ,lLf�,
4\ ��K. � � �.�. A�..
I heraby aifirm tha am ezempl from�he Contractor's Ucensa i � �.�+ ..
Law for tha following reason(Section 7031.5,Busfness and ADDRESS w � �/ n�1`���� �
ProfesslansCode): . � " � �i� �hUF_C- `�I3S�4Y• °�
_ Q . � BUILDING Q
i, as owner of�ha properry, or my employees with , no�RE55
wages as iheir sole tompensation,will do the work and
tha structure is nol imended or offered for sale(Section ����TY - -
70E4,Business and Professions Code). i MOVING TE�• - �
� I,as owner of the properly,am ezduslvely conlracting C NTRACTOR No. .. . �� 5 4.3 A-
with litensed con�ractors to constrvd the projett(Sec- I ADDRE55 • •�,
tlon 70<4,Business ond Professions Cade). -- -� ��� � �
REOUIRED TOTAL SETBACK FkOM EXIST.
CONSTRUCTION LENDING AGENCV � i SET BnCK �AR� FN�Y PROP.IINE WIDTH , . . .� •1 4 9.2 5
I here6y affirm thof fhere is a cons�r�ction lending ogency for I FRONT ' � �� I
�tha performance of tha work for which this permit is issued � P.L • 1 4 9.2 5�
(Sec.3097,Civ.C.). SIDF . � � ' �
P.�. , 0214-84
m Lender's Nome� �1'n L ( � � � �
� � P.C.Fea f' Permi�Fee ��Jy IJ� '
� lender's Address .. .
� I certify�hat I have read this opplica�ion and state that�ha - tssuo ro Fee � � ✓��
� obove informaFlon is correct.1 agree to tomply with all Covny Investlgo�ion Fea . .. . .
ordinonces and Stata lows relating fo bvflding consfruclian, Torol F�e 9. zr �
ty ond hereby outharize representarives of this County to enter �
� upon he above-menPone roperty for Inspection pvrposes. � . � � � - �
� �,� � - SEE REVERSE FOR EXPLANATORY LANGUAGE .
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