HomeMy WebLinkAbout1364A (7) - WORKERS'COM7ENSATION DECIARAitON � j - .� � f�
I hereby alfirm iha�I ha�a a certifitatne oF�o�,e�,,o=e�f � APPLICATION FOR BUILDING PERMIT ��;
insure,or a ter�ifimte of Workers'Com ensation Insuronce,
or a ce�i'rfied copy ihereof(Sec.3800,leb.C.) � �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. Company gUIIDING
� Cerrtied copy is hereby furnished. FOR APPLICANi TO FILL IN AODREA �3 � �
� Certiiied copy is filed with ihe couMy building inspec- � � BunDwG �^ . /�
tian department. ADDRE55 .T�'3 GG ��/�a ��.` .�"J•
Do1e ..APPlieont CITY Y/�INV` J �y�� ZiP �7�`� LOULITY -
CERTIFICATE OF EXEMPTION FROM WORKERS' - . NO.OF BlDGS. . NEAREST
COMPENSATION INSURANCE � SiZE OF lOT NOw ON LOT CRO55 ST. � � � � �
(ihis section need not be completed if the permit is(or ona .. S3 � ASSESSOR
h�ndred dollars(5100)or less.) . iRAtt � 3 BLOGK LOT NO. Mp,p BpOK PAGE PARCEL
. . TEL. O/�O ��� MAP
1 ce�tify thal-in Iha performonca of tha work for which lhis OWNER � . ' L Np, � O � � �Z�-,3 C`S
sermif Is fssued,I sholl nol em lo an erson in monner ADORESS � � Gy "�" D �G�� SPECIAL �
o os 10 become sub' ct to ihe WorkenPCom atton ws. �2 `� `�', ��- ���UQ CONDI7ION5 Q �
�/_ CITY �i�+'�-Ll.�t. .QIL 21P ����� V
�Da1e�Applitam � �
NOTICE TO APPIICANi; If, o�tar i thi Cerfifl of , ARCHITECTOR TE�. DI KT GROUP NPE FiRE PROCESSEDBY O
Ezempfion, y0u ShOVId beCome Sub�ect l0 1 e orken' ENGINEER �� �p�T. 20NE V
Compensalfon provisions of tha lobor Code,.you must forth- ADDaE55 � �
with comply with :uch provisians or this perm(t shall 6e
deemed revoked. TE�• StAtISTICAL QASSIfICATION ACT. CONDO. , ln
CONiRACTOR � NO. � Z
LICENSED CONTRACTORS DECLARATION � ,p ���,� _ QASS NO.�DWELL UNITS �
I here6y affirm�hat I am licensed under provisions of Chopter 9 ADDRE55 C.i' r10.
�commencing with Section 7000)of Division 3 of ihe B�sine5s and ��� ��R�P
Proiessions Code,and my licenee is in full force and eHetL � CITv QA55 BK � VALIDATION
� � � 54.fi. NO.OF L NO.OF CHECK
Li[ense Numbe� Lia CIaSs � SIZE � STORIES FAMIUE$ - - � ONE � �
❑ VALUATION
Contractor � Date � DESCRIPTION OF WORK .. N�
�I om exemp�under Sec. � � �j+ � •�� ADD � s �/ /� ,
ALTER ❑ �1 3 b 4 A
B.BP.C.for Ihis�eason REPAIR s �
Date: USE OF OEMp� �_• • • • • � .
E7(ISTING BLDG. �
APPlIG4NT •..TEL.
Slgnature � � -� - vk�M W(J/OAO . Q�. .j� NO.� ,�f�l FINAL � • •�l��Q
OWNER-BUIIDER DECLARAiION �/ DATE I Z � �
I hereby aifirm Ihof I om evempt from the Contractor's license � qDDRESS 23 Cl� ������,{� • '�4 a 0 0�
law for the following reason(Section 7031.5,Business ond �"—� FINAL
Professioni Code�: � � �- �- PRE ENT � " BY � (�9,Q(��8 8
BUiIDING
I, os owner o(the property, or my employees wilh aDDRE55 .
wages as lheir sole compensalion,will do 1he work and - �p�p,�ITY �
rhe:rruciu�e is no�imended or oFfered for sale(Section
7044,8usiness and Professions Coda). - MOviNG TEI. .
� I,as owner ot�he property,am exclusively contracHng COMRACTOR NO.
� with licensed coNroctors lo ronslruc/1ha projatt($ec- ADDRESS �
�ion 7044,Business ond Pro{essions Code).
- CONSTRUCTION IENDING AGENCY SET�BACK �ARO NWY T�TApgOP.lWE WiDTH .
I hereby aifirm thm ihera is a construttion lending agency for ieONT
the performon[e oI Ihe work(or which ihis permit is issued . P.L. �
(Sec.3697,Civ.C.). SIDE
P.L.
lender's Name � � �
3Z r7-� lDhV1 Ref.M
Lender's Address P.G Fee S Permi�Fee +.]•-+ � '
1 certify Ihat I hove read Ihis applicalion ond slate that the leevonce Fee /�� v LDMA P/C M
above intormation is conact.I ogree to comply wi�h all Co�nty Inven�gauon Fae �+
ordinances and Sta�e lawa relating to 6uilding construction, Towl Fee J��v LpMA Perm.N
cnd heraby aulhariza r resentotives of this Couny to enter
�pon the obove•me ned roperty far fnspectlon purposes.
�_� SEE REVfRSE FOR EX►IANATO�Y IANGUJIG[
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