HomeMy WebLinkAbout1405A 1887A WORKERS'COMPENSATION DECLARATION �rGY
insureborafcertifcateofWorkes'��Compensationlnsurancef � /"����'�Y1�i-�N FOR BUILDING PERMIT �S
or a certified copy ihereof(Sec.3800,Lab.�C.)
PolicyNo���ry3� Company5�'�f�f v� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified co is hareb fumished. L 6UILDING
❑ Pv' v POR APPLICANT TO FILL IN ADDRESS 'S 4��»Km(�u�l ��
� Certified copy is filed with.the county building inspec- BUILDING r y r ,,) /
tion deparfinent. ADDRE55 �-j 1�C�O✓:/� 3��'��c LOCALITY � I�r"��✓'�n �9�%
F^ " NEAREST /
Dote��f`"I���� APPlicant���(�k��� : CITv rQ�Y - �� �G�� ZIP CROSSST. G"r�.✓!�l
CERTIFICATE OF EXEMPTlON fROM WORKERS' NO.OF B�CGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if ihe permit is for one USE ZONE MAP
hundred dolla�s($100)or less.) � TRAC7 aLOCK �Oi NO. NO.
TEL SPEGAL ;m
I certify ihat in the performance of the work for which ihis OWNER ' = F ` NO. CONDITIONS C}
permit is issued,I shdll not employ any person in any manner / 1 DISTRICT GROUP TYPE FIRE PROCESSED BY 1,..
1 AD�RESS � �� �0�!�^�� �5�� �JI L'?� CON3f. ZONE �
so as to become s�bjeci lo fhe Workers'Compensofion Lows. � 1` f/� �„
. � . - CITY �.1j k-r�l(k. , q-C/� ZIP . (` .� c<.I..Gi �
OaPe Appliwnt - . � � � . SiA715TICAL CLASSIFICATION APT. CONDO. im
NOTICE i0 APPLICANT: If, after-moking��fhis Certificate�of ' PRCNiTECT oR�� � � � . TEI: _ ..:.. . - :i
empiiun, you snouici oecome subject�fo the Worker5� _, -CLA55 KO. �'� DWELL.�UNIiS_ "
_.:... _. �5.
Compensation provisions of Ihe Labor Code,you must forth- ,. qDORE55 � - � - � SEWER MAP �'�
with comply wi�h such prvvisions or this permit shall be � � � � �� �
deemed revoked. � J�J t� TE�"J p� � BK. PG, VALIDATION
": CONTRACTOR . G-%4,17�E' I'/ .t�//r NO. / '�Yj -
- IICENSED CONTRACTORS DECLARATION �i�J) �ff�`�✓'� �uc �-
I hereby affirm ihot I am licensed u der provisions of Chapter 9 � ��� ADDRES r 7 f NO. ,� VALUATION
(commencing with Secfion 700�)oi D vision 3 of the Business and . ��� t� /
Professions Cade,and my license is in full force and effetl. C�7Y �'�����A�-� Cta,SS �7 C 5 �`7 (� , 4� r=f L CL J�(�
„[._J t y�' �L%[ ^; SG1.Fi. NO.OF NO.OF CHECK }.� o 0 0'�`�
License Num6er r � � �J� Lic.Class �� F SIZE STORIES FAMILIE$ ONE � n ,2 5,0 0
S� � J � �-rC�"� �� DESCRIPTION OF WORK C�(ii�✓��f I. t'(%�1 S// NEW � b
Confractor����!7��r'C) fT/ Dafe�� � � r•c:�J,G(j��
�I am eXem f under$ec. ADD O
p A�TER � FINALr ��.C ����d
❑ DATE d ��e
B.BP.C.for ihis reason 2EPAIR
Dafe: : USE OF DEMOL FINAL -
� EXISTMG BLOG. ❑ BY ,.,� .
Signature . . APPL�CANT�y q� TEL.
OWNER-BUILDERDECLARATION PRINT ) Cv�7�: '+"�d/�yC No.
1 hereby affirm Iho�I om ezempt from ihe Contraclor's License ,
Law for fha Following reoson(Section 7031.5,8usiness and ADDRE55
Professions Cade): NT
Q �BUILDING
I, as owner of the property, or my employees with q�oRess
wages as their sole compensation,will do the work and � � �� �g,�p
ihe structure is not intended or offered for sale(Secfion LOCALI7Y
7044,Business and Professions Code). MOVING TEL 'fi7 a e m e m�
� I,as owner of the-properfy,am exclusively contracting CONiRAc7oR NO,
with licensed mntroctors to mnstrud the project(Sec- qpoRESS � � g`�V'�O
fion 7044,Business and Professions Code�.
REQUIRED TOTAL SETBACK FROM EXIST. o re
CONSTRUCTION IENDING AGENCY - SET BACK YARD HWv PROP.LME W��TH , "�J C•J�O o
I hereby aFfirm fhaf there is a construc�ion lending agenq for FRONT O 7Z O 2�8�
the performance of the work for whith ihis permit is issued P.i.
(Sec.3097,Civ.C.). SIDE
v.�.
Lender's Name - �
� ca�t�
$ Lender's Address � P.C.fee$ �.5 ^ �� Permii Fee d�/
I certify that I hove read�his opplicotion and state thai ihe issu ce Fee f C�• J ✓
� obove informmion is correa.I agree b comply with,all Coumy Iovesrgouon Fee an ,
ordinonces and State laws relating to building mnstruction, taal cee �S'�'� �a
and hereby au�horize represen�atives of�his CouMy to enter �
m upon the a.o e- entioned property for inspection purposes. �
a f ,'E�` ����t,
/��� t" SEE REVERSE FOR EXPLANATORY LANGUAGE
.��
. Signalore of Applicant or Agent Date . � � �s
i; �, � � � E � I � �.
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