HomeMy WebLinkAbout1011A 1581A WORKERS'COMPENSATION OECLARATION � - � � - ' '
� I h4ebp."alfirm ihal I have a�e.,��,�o,a of�o�5e�„o Se�f � � qpp��CATIQN FOR BUILDING � PERMIT � �
insura,or a certifito�e of Workeri Compensaiion Insurance,
or a certified copy t�reoi(Sec.3800,lab.C.)l�� � COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pality,Na, Company � �'✓� � � . �
rtified co is hereb furnishad. , � BWLDING ry
❑f' PY Y FOR APPLICANT TO FILL IN ADORES$ /�� ,c.s..,.,�,G � -2/�
� Cer�iffed copy is liled with the coonry building inspeo- BU��D�NG t��� A�/�
Iion dep rtment. nooRE55 �/�/�'1(�.� • 4-�1G /�'-
Oate Applicaro f Y/U•✓►�r CITV 21v � � �p�qtliV
ERiI CATE OF EXEMPTION F M WORKERS' � � � � NO.OF 6LDG5. - NEAREST
COMPENSATION INSURANCE � Size OF�oi NOw ON ioi CRO55 Si. � � � �
(This section nead not ba complefed if tha permit is for one 7RACT � BLOCK l0T NO. ' '�ESSOR-
hundrod dollars(5100)or less.) 61AP BOOK� PAGE PARCEL
� al TEL. USE ZONE 1dAP- � �
I ceriify that�in tha pertormonce of Ihe work for which this � owNER IV NO. NO.
parmit is iuued,I shall not employ any parson in any mannar 2 . . SFECU.I - �y
so as to bacome subject�o Iha Workeri Compensalion Laws. � ADDRE55 CONDiiiOn�S 0
• V
Dale Applimnt � � [ITV 21P � , �
NOTICE TO APPLICANT: If. atter mekinn�this Certifi:�!e cf ARCMITECT O TEI. i 4� DISTP.!R G?Ou? ttPE f!oc PRO�:S:p�Y O
Exam fiOn, � . ENGINEER NO. SU � .
p you sho�ld become sub'eci to �ha Workers' ! COnST'j�''A/ 20�vE V
Compensation provisions of the labor Code,you must farth- ApDRE55 G� -2 —+�-�`� 3 M�� W
wi�h comply wilh such provisions or Ihis permit shall be TE� LL'
deemed revoked. . � CONTRACTOR Np q��� STATISTICAL CL45SIFIG4TION � APT. CONDO. (/7
Z
� UCENSED CONTRACTORS DECIARATION . - .. � . ���.�,n���1 QAS$NO. DWEIL UNITS '
I haraby affirm Ihat I am licensed under provisiona of Chapler 9 ADDRE55 D�O NO.7'� Y
(commencing with Seciion 70D0J of Division 3 of the 8usiness ond /'�� � ��� ��R�
Professions Code,and my license is in full force and effect. Gitv � � L�/i: CLn55 BK � VALIDATION
�i 54.FT o0 N OF NO.OF CMECK �
.License N�mber.��Lic.Class Y � SIZE STORiES FAMIUES ONE
� ��lL� /�(�,�\h� � l� VALUATION
COMraCtor"uA^' Ui�yVT Date ' DESCRIPTION OF WORK �I� NEW.. � � � L 1 O,., A
LWt � `C�L ADD �
� ❑I am eaempt under Sec. - A�TER � #� � � �2�
B.&P.C.for this oson �s�"� REPAIR s �
- �ate: USE OF 0 .. , I • 1 5 8..5 3 .
exisrwc eioc. ouna
Signature - � APPUCANT 1f�-' TEL • • � �(�S,�J Q cSi
vRINT L�l N , 83� FINAL
' O ER-BUIIDER DECIARATION �.DATE
1 here6y affirm ihai I am exemp�from tha CoNractor's License � p� �� " � �( � � 0 8.1 9—8 8
Law for ihe following reason(Section 7031.5,Businass and /+DDRE55 FINAL
Professions Coda): - - ' `��� �'� ' �� gy
� 6UILDING
1, as owner of the proparty, or my employees wi�h ADDRESS
. wages as Iheir sole tompansation,will do ihe work and �p�AuiY � <1 5 E.1 A
the strucl�re is noi intended or offered for sole(Settion
70a4,B�sineis ond Professions Coda). -�� MOYWG � - - TEl• t�• • • • •.�
� I,as owner of Ihe property,am axcluaivaly contracting CONTRACTOR NO.
wiih licensed conrracrors to consuuct tha project(Sec- nooqess � - � ' I • � 9�,Q U
' tion 7044,Busine:s and Professions Code). .. � .. _ ,,
, � � � CONSTRUCTION IENDING AGENCY �� � SEPBACK YARD HWY TO1Ap OTP.LCNE WIDTN � � � � • � `7 Z O O c=i
I hereby ofiirm that there is a construction lendin9 a9ency for FRONi
' �he performance o(the work(or which this permi�Is Issued � v.�. � . �9.� 3-�8
' (Sac.3097,Civ.C.). SIDE
' P.L. '
' lendar's Nama � - -
(� �^7 L� IDMA Ref.N
m � P.C.Fee S Si}iv�7 Permi�Fae •✓O ,
lender's Address -
' � I ceriify that 1 have reod this applicotion and state thet the i,,,,a„�e pa, ��'S� toneq piG N
obove i rmalion is torract.I ogree to comply with all County Inrestiyaiion Fee �
' q otdin c ond Stole law ralating ta building construction, Ta�al F •O I�MA Perm.N
and er y ouihorize re res tatives of this Counly to enler
up e ove•mentio d ro rly tor inspettio pur oses. �
� B SEE REYERSE FOR EXPLANATORY IANGUAGE
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