HomeMy WebLinkAbout1208A WORKERS'COMPENSATION UECLARATION '}
I hereby affirm Ihot I hove o certificate of consent to 5e�t . qppLICATION FQR BIJILDING PERMIT ��
insure,or a cerlificate of Workers'Compensation Insurance,
or n certi(ied copy the�eof(Sec.3800,lab.C.) � COUN7Y OF LOS ANGELES BUILDING AND SAFETY
PolicyNo.����-3�Yi.� Compnny_5�.� �t)'Ywt.7
� Ceriified copy is hereby lurnished. � FOR APPLICANT TO FILL IN d'���u�N" � � ` � ���„ �ry,v�(p
�DDRE55 �.a��a:3�, �.
Y-'1 Certified copy is filed with the county building inspec- � yUIiUING ,• d r'
LJ tion deparlmenl. ADDRE55�..�._-�3L� �. �/[tJ•Y�r�nt� 712i��. LOCAII�Y ��S;,�ij, �
�'� ��/�� NEAREST
9ate �, l " � /�PPlicaniG��.�,N��/�( y,sLo� (.'I�Y f.2J�'tbrll�. 71P _�_ CROSSSI. W.W
CERTIFICATE OF EXEMPTION FROM WORKERS No.Or uLUGS. As5E55oR
COMPEMSATION INSURANCE SILE OF LOT ___ ___ NOW UN LOT MAP BOOiC PAGF PANCEL
(This section nend not be completed if fho pennit is for one 7NAC:T BLOCK Ipl NO. USE 70�E OF � �
hundred dollars(5100)or less.) l
IEL. �) SYICiAL ;s.
I certify thot in the pertormance uf the work for which this UWNFR L�.� �^ NO. ��G-�C�.��j � � <T CUNDITIONS �
permif is issued,I sholl not employ any person in any manner ,. � .., DISIItICT (,ROl1P iYPE FIRI PROCESSED BY �:,1
so os to becomn subjeci�o the Workeri Compensofion Lows. �CDRE55 ; ��j,.' 1�L.� �J r�� �- . �� CONSi. 'L(� (� �4 ��°
/1 \\ �.,:
�ate .—A �iCaP� CIIY CiC�(:(�Pn.. 4�slLur_. _ZIP C a��r �O t�li �ms
PP -- . -" �-`---L-- STAI�STIC:AI CiA551FICA710N ANT. CONUU. q-.
NOTICE TO APPLICANT: If, ofler makiny this Certificate of ARCIIITECT UR � . TEL. . R�
Exemption, you shoUld beCome SubjeCt to the WOrkers' ��'yGINEFR. � _ NC. CLASSNC�. DWELL.UNI1S tu
.1_
Compensation provisions of the Lqbor Code,you musf forlh- qpDRESS ' � SEWbR MP.P ;°�
with tornply with such pro�isions or this permit shnll be :` �E� yq��DATION
deerned revoked. CONTRACipR � j� � (t/:i NO��, C �, BK. PG. •.�•
LICENSED CONTRACTORS DECLARATION � i��
I hereby affirm 7hoi I nm licensed under provisions of Chnptnr 9 ADDRE55,� �• �� � � NO.��.��, �'1 O%2- VAlUAT�ON
(tommencing with Seci�on 7ppp�of Division 3 of�he Business nnd ` y� ��� � 1 /`I�.
Professions Code,ond my license is in full force and effecl. f.ITY`..)LL��, cr-� �-I�.�� �,��C� CLA55'�-�,l� S� �vtJ
1 ,
3� � [I SCd.FT. � • • �O.C1F NU.Uh CIIE.'.K r�
Liconse Number �������r Lic.Uass- ���-� SITE STORIES FMhltlES O�F /�
�j p ' � NFW � S I
Contracfor �(l`.`•>S f� /�'i!lOi��S riF]ate �'.)�/•t�� � UESCKIP110N OF WORK //'�'' /'i�t
❑ r�.�'I'
AI)f) `y .
❑I am exempt under Sec. ��• C�" � � ��� �'ZFl � �-� q�7EN � FINAL � .,���
B.8P.C.for this reason REPAIR .� DATE �!;.i. �%,
� USE OF
Date: �' / ,,�..,�� DEMOL ❑ �NAL '�.
EXISTING BLDG. .:t • : ,-..r�J� y
Signalure AVPLICANI � � 11'7. ;.
OWNER-BUILDER DECLARATION PRtNII L7.YC5'�c -� � s�/,cl/l•�n•�..S.>I"J�/�/G� �Il.�.'� � ,. �`�'.
I hereby allirm inat I am exempf from iho Contractor's License ) 'L J �' �,a�'"�� �(1 �``� ,r'f
Law for ihe following remon(Sectian 7031.5, Business ond AUDRE55 r>C :G' E" ���/O;t•' �Cd.n.�(2,- �'7"�� � � �
aP�'�, '.11:�°�«'`*u.
ProEessions Cedc): pKF-ryT . ;,a �r
❑ BUILDIN(i — .S .�1a1�
I, as owner of ihe praperty, w my employees wilh ADDHESS �!f� 1����� �'�
wages as iheir sole compensation,will do the work and �+f ,���•��1.`�`�,j'� •r' ; �
ihe siructure is not intended or offered for sale(SeUion LUCALITY }{+� / � 1 �s `! .'�i G lj,C)!�1
7044,Business and Professi0ns Code). MOVING TEL ( �r P'y � i"'��
� I,os owner of 1he propeny,am exdusively mntraUiny CONTNACTOR Np. � `� , A'�' y` j(° u ° ° e �
1' t �p
with licensed coniractors to constrvct the p�ojeci(Sec- � �� j. f d �,�, �;�
� ADDRE55 J ��v�J
tion 7044,Business and Professions Cade). f'�7 l �' �� �
REE.�UIRED TnTAI$FTi�ACK FRUh� 1'XIST. �f
CONSTRUCTION LENDING AGENCY SF.7 BACK YAND HwY PROV.LI�E �N�DTH 1`'�✓ � � �� �2:U 5 fi�;
I hereby affirm ihot there is a construclion lending agency for �k���� ��
the performnnce of tl�e work for which ih�s pe.m�t�s issucd v.i. , �;� 1/4_Zj�
�Sec.3097,Ci�.C.�. SIDf
P.L.
Lender's IVame
Lender's Addrr.ss
P.C.Fa�$ f'ermit Fee ��`�
I certify that I have rzad Ihis opplir.ntion and state Ihot fhe Is.wa ce Fae `��C
above inlorrnation is correr.t.I ogree to comply wifh oll Counfy Invesi�gni�on Fnn ��
ordinances and State laws rr.laiing io building consiruction, �Q C�
und he.reby authorize representatives of this Covnty to enter �otnl Fee
upon ihe above-mentioned proper�y for inspec�ion purposes.
L.i 7i ' ��r�,if�,L,�,,ry��/;,.,(. ���•l�� SEE REVERSE FOR EXPLANATORV LANGUAGE
` Slgnn����o o�A� icaM or Agen� Date Pis
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