HomeMy WebLinkAbout1648A VJORK[RS'COMPf:NSATION DECLARATION ��
Inhe(�bor�"��P,;f�°;��o1fVJor�'�enr'Com'per�sationslnsuran�" APPLfCATIQN FO� BUILDING PERMIT` �
o�a certified topy therenl(Set.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Campany c
� Ce�tified copy�s V�ereby fur��shed. FOR APPLICANT TU FILL IN _ noriRf55__�Q`�_Jt,y��4{�I�MiXvl a.-�
❑ Certified copy is filed v+iih the counry buildiriy inspec- BUifDING �,.�� � c /,
tion department. �\DDNESS _ _ p�
Dale Applican! CIiY ZIP � ' LOCA!ITY � P W��_"��ti�"�.^�—
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEARE51"
COMPENSATION INSI!RANCE 51[E OF LOT NOW ON t07 CRO55 ST.
(ihis sect�on need not be campleted il the pe.mit is for one A55ESSOR
hundred dollOrs($100)or 1055.} TRACi BkOCK lOT IhO. MAP BODK PAG[ ___ PARCEL
pVdNE
E J USE ZONE NW?
I cerlify tho�in ihe performance of the work for which this _ NO. _______„_ �
permif is issued,I shall nof employ any person in any manner SPECIAL q�
ADDRE55 ` ' "•( � CONDITIONS
so as to become subject to ihe Workers'Compensation Laws. � _ �
Date Applimnt CiIY /�iL+�� � l ZIP �� �
NOTiCE TO APPLICANT: If, ofter making this Certificote of ARCHITECi OR y 7 ": .- TEL (" � DiSTRICY GNOUP iYPE FIRE PROCESSED BY C)
ENGINEER �/ � -GJ NO. .7 � �� �p , ZONE \ a"
Exemplion, you should become subject to �he Workers' �/,/ / �/� ( C�`C� CJ
Compensotion provisions of ihe Labor Code,you must forth- qpDRE55 �l �'� �W�'(%�N 'V �° � (`x �"
with comply with such provisions o� this permit shall be � � - �� �'1"
deemed revoked. SiAi15YICAt CLASSIFICAT�ON APT. CONDO. U.1
CON?RACTOR Y—^ NO. �— � t'.".
LICENSED CONTRACTORS DECLARATION � uC. _ cia55 NO. 'DwEu.urvrtS
I hereby affirm thoi I om licensed under provisions of Chapler 9 ADDRE55 -- �0� SEWER nAAP
(commencing wilh Section 7000)of Division 3 of Ihe 6usiness and LIC.
Professions Code,and my litense is in full force and effect. CITY CiA55 e,� � VALIDATION
SQ.FT. NO.OF NO.OF CHECK
LiCense Number__ Lic.CIa55 SIZE STORIES FAMILIES ONE
. VALUATION
DESCRIPTIONOFWORK �� �EW (�
Contractor Dale � '+ ,r� ADD s � �`�' ` ,
�!am exempt under Sa�. �L L/' AL7ER
❑
B.&P.C.forthisreason REPAIR ❑ s
Dale: USE OF DEMOt ❑
— EXISTING BLDG.
APPLICANT�/' 7EL.
Signature PRIN?) .�J ' i.�0. 'f FINAI ��'I �;(I.fi!�`�
OWNER-BUILDER DECLARATION DATE
1 hereb affirm thol I am ezem 1 fram tfie Con7racior's License
Low fo�the following reason(Sattion 7031.5,Business and ADDRF.55 �J� '� p�Nq� �'.w u a »%()
Professions Code�: PRESENT ( � B� � , ��.t�C.r
^ BUI IDING
lu I, as owner of the oro�>erly, or my employees with ADDRE55
wages as their sole compensation,will do the work and � m a� 4���•,���)J
the struclure is not intended or offered far sale(Setlion LOCALITv
7044,Business and Professions Code). MUVING �F� U 9,1 1-�i�:�
� I,�5 owner ol ihe propeny,am exdusively contrnUin� CONTRaC70R NO.
w�th I�cer,sed to��rp�tprs to con5trucl ihe projeCt(Ser: qDDRESS
tion 7044,Busiriess and P�ofessions Code�.
kEC;UIREU yqRD HWY TOTAL SETBAIX F M
CONSiRl1CTION LENDING AGENCY 5[T BACK PROP.�iNf WIDTFI
I hereby atlirm ihai there is a construc�ion lending ayency for FRONT
ihe performance of the work for which this permit is issued v.l.
(Sec.3097,Civ.C.). SIDE
P.L.
Lender's Name (� ;DMA Re(.M
P.C.Fee S �-���-'� Perrnn Fee ,
Lender's Address,.
I certify�hai I have read this applica�ion and state 7ho�the I.esunnce Fee LDMA P/C N
above information is carrecl.I agree to comply with all Counfy invasiigation Fee
ordinonces and State laws relating to building co�struction, iotal Foe LUMA Perm.N
and hereby autharize representatives of�his County to enier
upon the above-mentioned proper�y for inspection purposes.
SEF REVERSE FOR EXPIANATORY LANGUAGE
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