HomeMy WebLinkAbout1327A 2191A (13) WORKERS'COMPENSATION DEC�ARATION 11
incure6or7ifcertifhmtteofWorkersrtCompensaion��5�:a�a'f APPLICATION F4R BUILDING PEitMIT L�
or a cerlified mpy ihereof(Sec.3800,La6.C.) ;i
�� COUNTY OF LOS ANGELES BUILDING AN�SAFETY
P❑olicyNo. Company .�
Certified copy rs hereby fumished. F�R APPLICANT TO FILL IN ewiow� f .�- �N���f ��
ADDRE55
� Cerfified copy is filed with the counly building inspec- �} BUiLDING :.- /�� �M �9y7 �
tion depafimeni. ��� ADDRE55 '�1r1.. [.YP.�•,' /o LOCAi1TY ` '-��
j; �' ,Y� NEAREST
Date Applimnt :��, CITY ��/�i ZIP CRO55 57.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF s�o�5. ASSESSOR
COMPENSATION INSURANCE ' SIZE OF LOT NOW ON LOT MAP BOQK PAGE PARCEL
(This section need not be completed it ihe petmit is for one t USE ZONE MAP ) ;�
hundred dollars($100)or less.) �, TRA�T B���K �OT NO. NO. /�'���
�(J'�y7r•(„E:r" TEL �"� SFECIAL ?^
I certif that in the erformance of the work for which this - �wNER 7P NO. CONDiTIONS �
y p p14RICT GROIJP TVPE FlRE PROCESSED BV G
permit is issued,I shall not empby y person in ony anner � / � CONST. Zqq� �
� ADDRESS �7�
so as to heg6me s ject to the W ers'Comp w� aws. . .7 (� •�! u �
� ' :' CITY � ' ZIP [;.�� , d �
Date App�iC TEL STATISTICP.L CLASSIFICATION APT. CO O. �
ARCNITECT OR
NOTIC TO A L ANT: If, , te making this Certificale of ; FNr.iNEca ' S5 J"v. o��) uweu.uNnS_ - n�
°��g;p;;ary yov ciiuu u ' �come suojeci io �ne riorKerS � - �- �
Compensation provisions of the Labor Code,you must forth- �� qDDRE55 SEWee rnaa �
with comply with s�ch provisions or this permit sholl be TE� "'
deemed revoked. ' CONTRACT � � .(l�NO. BK. PG, VAUDA710N
LICENSED CONTRACTORS DECLARATION `. }� ,,q' uC.
I hereby affirm ihat I am licensed under provisions of Chapter 9 �� ADDRE55� � �.C.�' `,✓� �7n-�NO. VALUATION t'� ?,�7�
(commencing wiih Section 7000)of Divisiod 3 of�he Business and i ' . p�,I�� uc. -
Professions Code,and my license is in full force and effetl. � CITV . r ✓� CLA5S 5 � , �p �, i; o�i.
� - SQ.f7. NO.OF� NO.Oi CHECK
f�0%1
License Number Liu Class SIZE � STORIES FAMILIES ONE
g � o a.�9,�G
�r DESCRIPTION OF WORK ���9 NEW � � � a � 1
Confracfor Date � ADD �:$ �`'�'�.':l:`
�I am exempt under Sec. � �� � ALTER � FINAL � . ' /
,� O DATE . i�r !� U i��t"'t�cS
B.&P.C.for this reason � REPAIR
Date: � ' U5e oF � - �� oEMOt � FINAL � � ,
' EXISTMG BIDG. � gY ..,y� -
Signafure � APPLICANT.� .. - TEL � . � ' �
OWNER-BUILOER DECLARATION PRINi No. _
I hereby affirm that I am exzmpt from the ConPracPor's License �� qDDRE55 /r/ � '�,
Law for fhe following reason(Setlion 7031.5, Business and -�� � i �
P fessiOns Code): � . PRESENT- �
-BUILDING j , .,,� 'j/� a'",2f'� pd�
I, as owner of fhe�property, or my employees with A9DRE55 j7 a e u o � �
wages as their sale compensation,will do the work and
the structure is no�fntended or offered for wle(Section �OCAIITY J � ti fi U,�r�
7044,Business ond Professions Code). MOVING TEL.
� I,as owner of the property,am exclusively confracting CONTRACTOR NO. ti �, t�,�r�l�`
with licensed tonirociors io mnstruct the project(Seo- qpDRESS
fion 7044,Business and Professions Code). ��i S':i J-"�J
REOUIREO YARD HWY TOTAL SETBAGK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET eaCK PROe.uNE WiDTH ,
I hereby afFirm ihat ihere is a consiruction lending agency for FpON7
fhe performance of Ihe work for whicb ihis permit is issued P.�.
ZSec.3097,Civ.C.). 51DE
P.L.
� Lender's Name �—^�� /^�
� P.C.Fee$ a� r�l (J Permit Fee /�-Uy
Lender's Address
� 1 cenify�hot I fiave read this application ond state that ihe Ism ce Fee �4',�
¢ above information is correct.I agree to mmply wiih all County Invesiigo+ion Pee an
g ordinonces aad Stafe laws relating to building construction, Total Fee ��"��
i"i and reby authorize iep sentatives.of ihis Co roy to enter
� up ihe above-m tiQn roperty for inspazJ' n pur oses. �
� I ,�y SEE REVERSE FOR EXPLANATORY LANGUAGE
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