HomeMy WebLinkAbout1726A 1883A (17) � WORKERS'COMPENSATION DECLARATION
insurebaraafcertifcatteofWakersr'Compensatioolnsurancef �� APPLICATION� FOR BUILDING PERMIT �
or a certified copy thereof(Sec 3800,tab.C.) - '� ` CpUNTY OF LOS ANGELES BUILDING AND SAFETY
V�olicy No. .c+7.J 6 Company ��� � �
Certiiied copy is here6y furnished. � FOR APPLICANT TO FILL IN noosess
� Cenified copy is filed with the county building inspeo- BUILDING �
fion dBpartmeht. - ADDRE55 �� �� LOCALITY /'QN1(J
�.�l lA�.�. NEAREST
Date ApplicaM .� CITY f�f�7��/�C� ZIP CRO55 ST. �
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. A55ESSOR
COMPENSATION INSURANCE `� SIZE OF LOT NOW ON LOT MAP e00K PAGE PARCEL
(This section need not be-compleied if the permit is for one use ZONe MAP
hundred dollars($ioo)or less.) rencr aiocK LO?NO. NO.
- /+ �" �y�� TEL SPECIAL
- I rerfify fhat in ihe performance of the work for which fhis � OWNER e,`.p (TQi �W/�t'� NO. CON�ITIONS �-
� `� �� fj � �iSTRIC7 P TYPE FIRE PROCESSF �
permit is issued,I shall not employ any person in any manner i AODRE55 S ` 0( �,/ ST. ZONE � 1 4-i
so as ro become subject to the Workers Compensation Laws. / ZiP `� � ���� U t
' arr �Q+�Jsta��Gr
Date Applicani STATISTICAL CLASS�FIG4TION APT. C N . t�
NOTICE TO APPLICANT: If, after making this Certifiwte Of ; FNRNIFFpTOR �E^. .-�.-1
Ex.e.mp!?o.^. .. ---- uje me Workers' — CIASS NO. (,��DWELL.UN775_ ^
Com ensation rovisions of ihe�Lobor Code,�ou must forth- �'Z �` /� �3
P P y �� A�DRE55 V(w 'es� Pc CT SEWERMAP
winc �omply with such provisions or this permit shall ba �} �
deemed revoked. . rq�j st7y✓d NO..lff (t gK. p�, VRLIDATION
�� CONTRAQOR
LICENSED CONTRACiORS DECLARATION i ���.
I hereby affirm ihat I am licensed under provisions of Chapter 9 A�DRE55 Qt�9t-'f" NO. ' yAj.0 TION
(commencing ith Section 7000)of Divisio�t 3 of the Business and LIC. j /1� �
Professions Code,and my license is in full force and effect. �� ciiv CLa55 c� § 1 t< ,F� ��L�h A
C� ' Sq.FT. NO.OF NO.OF CHECK ►
License Num6er ��� Lia Closs � SIZE STORIES FAMILIES ONE
� �e o� u 2�
ConifOc�ol Dofe � � OESCRIPTION OF WORK � Q Q . (• A D � � m �C�.�:C
�I am exempf under Sec. ALTER � FINAL � `�t��,(i�
DATE
B.&P.C.for ihis reason REPAIR � �2�G s���
� USE OF fINAL �
Dafe: � EXISTING gLD6. �EMOL ❑ ��
Signatore
�� APPUCANT TEL. BY ""'
OWNER-OUILDER DECLARATION PRINT) NO.
I hereby offirm that I am exempf from ihe Confracfor's License
Law for the�following reason(Section 7031.5,Business ond ' ADDRESS �
ProfessiOns Cod9): � PRESENT
❑ . �BUILDING
I, as owner of ihe property, or my employees with � ADDRE55 °1 8 3,3 A
wages as their sole compensation,will do the work ond -
the strucfure is not in�ended or offered for sale(Section � LOCALITY �,� a o�� �,�
7044,Business and Professions Code). - MOVING TEL � .
❑ C NTRACTOR NO.
I,as owner of fhe properfy,am exclusively rontracting �( � a j(a'�5
with licensed coniraUors 10 consiruct the project(Seo- qDDRf55
tion 7044,Business ond Professions Code). • • e J t�7 J cai
CONSTRUCTION LENDING AGENCY . RE4uikED SOTAL SfTeACK FROM exisi. �
SET BACK YARD HWY PROP.LINE W�D7H
I hereby affirm fhaf thare is a consiruction lending ogenty for. � � FRONT � , �3,�2�8�
the performance�of the work for which this permit is issued � P.L.
(Sec.3097,Civ.C.).. � . . ' � . SIOE � � � � . - � � . .
. . , . . . � P:l . - ' � . ' '. . .
m Lender's Name � � - �
� Lender's Address P.C.Fee S ���� Permit Fee �� .(.fj
� I certify that I hove read this applicalian and stafe}haf the � Isauance Fee �( -...S���
� a6ove information is correct.I agree to mmply wifh oll County Inves�iga�ion Fee
$ ordinances and State laws relating-to building construction, Totai Fee „� , �,.j�
and hereby au�horize r presentatives of this CovMy�o enter .
m upon�h above- e ti ed operty for inspection purposes. �
a
� . .� . SEE REVERSE FOR EXPIANATORY LANGUACsE .
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