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Home My WebLink About1117A 3162A (5) WORKERS'COM7ENSATION DECLARATION �� I hereby offirm ihat I hove a certificote o4 conseM Po salf APPIICATION FOR BUILDING PERMIT " insure,or a certi4imte of Workers'Compensation Insurance, . or a certified copy thereof(Sec.3800,Lab.C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company eUiLOiNG � Cerrified mpy is hereby fumished. FOR APPLICANT TO FILL IN ADDRESS ��/��Qti'��/�'�. n Certitied topy is filed with the county building inspec- BUiLDiNG � LJ �{an departmenY. ADDRE55 � 5� � P�✓ � Date Applica�t CITY +i��9 ZIP LOCALITY /�+�� J�/� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. NEP.REST COMPENSATION INSURANCE SiZE OF LOT NOW ON LO7 CRO55 ST. ��n "� (This section need nof be completed if the permff is for one ASSESSOR hundred dollors($100)or less.) TRACT � BIOCK LOT NO. Mp,P 800K PAGE PARCEL t TE�' USE ZONE �P I cerfify that�in the performance of the work for which ihis OwNER i, p1hQ.6+1, ENO. �)�� p ,�,3`�-'' permi�is issued,I shall not employ any person in any manner qpDRE55 �i �. r$�� SPECIAL � so os to 6ecom su6ject ro the Workers'Com -' sa�ion Laws. f�� '�` �� CONDitiONS 0 Dme(��Applimnt • ' � CITY - ai +J4'w� Z�P .1/ LC NOTICE TO PPLICANT: If, after making is Certificafe of /+RCHITEC70R TE�� DISTRICT GROUP NPE FIRE vROCE55ED BY ENGINEER NO CONSL�___.. ZONE Q Exemption, you should 6ecome subjecl to the Workers' `� � ��p` U Compensation provisions of the Labor Cade,you must forth- qD�RE55 �. .r7 � '� 'v'�tA �.e� � �� `�' ��-0� � with comply with such provisions or this permii shall be .� )?ei.7� ST0.TISTICAI CLASSIFICATION APT. CONDO. (�j deemed revoked. CONTRACTOR n x ��'f�yS�+S�,lve,�NO. 9� Z LICENSED CONTRACTORS DECLARATION ii�. C1A55 NO. �`�DWELL.UNITS I hereby affirm thot I om licensed under provisions af Chapter 9 ADDRE55 � NO. �3 �yyER MAP (commencing with Section 7000)of Division 3 of the Business and ; ��. Professions Code,and my li<ense is in full force and effect. Ciiv �' fr�2� � . C1n55 � BK � VALIDATION 5a.FT. NO.OF NO.Of CHECK License Number__a�Lic.Class� SIZE D STORIES FAMIUES ONE :-_`�'. � � 1.7 A 11 �,`� VALUATION Contrac�o��Qs+ Y«'�+)ate �� c. DESCRIPTION OF WORK �r�N'L NEW 0 s �� , ?�.o e a c i 3 � ADD � �1 pm exempt under Sec. �• � / � ��''�� ALTER ❑ s .. r.('� I.J��u B.&P.C.for 7his reason ' EPAIR a USE OF �,�j�%-�'� J^��' EXISTING 8lIX'i. � /1/� - DEMOL ❑ �. �. Signature� APatiCANT � L FINAL "'� . OWNER-BUIID R DECl+4RATION PR�NT � a' � � �� DATE / I hereby affirm that I om ex�l pt from the Coniractar's License Law for the following reason i5ection 7031.5, 6usiness ond AooRE55 N Ft�! +�'� Professions Code): BY � BUILDING I, as owner of ihe properry, or my empioyees with ADDRESS wages as their sole compensation,will do the work and the str�cture is not intended or offered for sale(Section ��U`��T� � %.�� (7 G A 7044,Business and Professions Code). MOviNG TEL. � i,as owner of fhe prope•ty,am exclusively controcting ��N'fRACTOR NO, (-,+o y m o � � with licensed contractors to consfrucl the project(Sec- qDDRE55 � ° + g��O iion 7044,B�siness and Professions Code). �;� .,�! �� CONSTRUCTION LENDING AGENCY �gqCK �ARD HWV TOT'4�p�5E�Tp'4�NEFR WI�TH I hereby affirm that there is a construction lending agency for FROM � �`5��7 she performonce of the work for whith this permil is issued Rl. �Sec.3097,Civ.C.). SIDE P.L. Lender's Name_ /'� ,�� q L�MA Ref.k � P.C.Fee$�(OI*�' Permit fee �V� •S� , ' Lender's Address � 1 certify tha�I have read 7his applicalion and slate lhat the Issaance Fee ��``�~� IDMA P/C M _ above information is correct.1 agree to comply with oll County Inves+iga�ion Fee ?� '�v ordinances nd State laws relating to building consirucfion, to+al Fee o� LDMA Perm.N ' and here uthoriz r esentotives of�his Couniy to en�er upon! above-men� property for inspection purposes. , � . !.. P"+�a�'py� '� EREVERSE N ANGUAGE � �T��,�'��" -��-�t;� �'��T r Signature of ApPllcont r Agent _-� Da�—�� i.�_��.� _...__. .._.� T:,_'.w� � l �.*•�6Tj : . �;'( ',Ti:" ::; _'7::.�,�`r�,�.�i._.....,�.�._._�......_.._.�.-- l ' .� ,_ '' Z . ,WL�:tt=.�.v' „ ..v`.!' 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