HomeMy WebLinkAbout1217A 1218A (6) WORKERS'COMPENSATION DEQARATION � � � - - �
I hreby afF�rm ihar I have o cer�ificote af consent to eelf App���CATION FQR BUILDING PERMIT �
iniore,o�a ce�tificale of Workeri Compensotion Insurance, �
� o❑raYertifiedcoleoc�P7�f��+�a.3Y00,��C.)- �� COUNTY OP LO$ANGELES BUILDING AND SAFETY
Polic No � an � BUIIDING �l � �1 `yL��
Certiiied capy is hereby furnished. FOR APPLICANT TO FILL IN ADDRES$ �j• JV
� Cerlified copy is filed with�he co�nty building Inspec- BUitDiNG / / ��
IiondeporimeN. n A�DRE55 b 4"b /V- ��7�L4 M
Date �•• •��Applic t � L< �.� CITY �Ot�'f n Lt✓� ZIP LOCAIITY t ���
CERTIFICA OF EXEM TION FROM WORKERS' NO.OF BlDGS. NEAREST
� COMPENSAiION INSURANCE SIZE OF tOT NOW ON LOT CRO55 ST. '
(This section need not be tompleted if the permil is for ona /+SSESSOR
'hundred dollars(5100)or�ess.) TRACT BLO�K tOT NO. MAP BOOK PAGE PARCEL
,1� / TEI. USE ZONE µ1P 1
I certify Ihat in the per(ormance oi the work For which Ihis OWNER /v (A� A NO. �
permif is iSsued,I shall nof emplay ony person in any manner qD�RE55 ' `] /�l SPECIAL Q
so as to become subject lo the Workers'Compensotion Laws. CONDITIONS Q
Date Applicanl CitY ZiP �
NOTICE TO APPLICANT: If, after making�fhis Certiiicafe of ARCHITECTOR TE�. DISTRICT GROUP TYPE FIRE PROCESSEOBY O
Eaemption, you should become svbjett fo Ihe Wo�ke�s' ENGiNEER No. CpySL.--,� ZONE U
/�.` ♦\
Compansarion provisions of the Lobor Code,yo�must forth- qDDRE55 �v U W
wiih comply wiih such provisions or this permit sholl be I �-
deemed revoked. . Gl/ej-r �,e TE�� STA715TICAL CLF SIFI ATION APt. CONDO. z
COMRACTOR 4� C��O��/l —7S�F
LICENSED CONTRACTORS DECIARATION ���, � M55 NO.�DWELL.UNITS
I hereby affirm that I am licensed under provisions oF Chop�er 9 ADDRE55�� r � � n70. 7�
(commencin9 wirh Section 7000J of Division 3 of the Bosiness ond UC. ����P -
Professions Code,ond my�itense is in full force ond eNett. CiTY Gt/��+ /''t v� QH55 � VALIDATION -
� /-} SQ.FT.� �NO.OF NO.OF CHECK gK' �'
License Num6er��Lic.Closs •U SIZE STORIES FAMILIES DNE
VALUATION
Conrraclor 4/�t'-� G-�C'� pme - O $ DESCRIPTION OF WORK � SP� n,C,_ N� � f I
AOD � •� ,
❑1 cm ezempl�nder Sec. � � � �
e� ALTER
B,BP.C.for this reason . 1 Z.� REpp�R � S .
Defe:T?� USEOF DEMOI ❑
/ EXISTING BLDG.
Signatur � /� APaIiCANT \ � _ /, TNO. 3- `7_j FINAL lU l�}�� . .
' OWNER•BUIIDER DECLARATION PR�NT J /C.�. DATE i f O
I hereby offirm that I am exempl from the Contractor's Licensa -- � r _ '
tow for Ihe following reasan(Section 7031.5,B�siness ond ADDRESS � — FINAL
Professlons CodeJ: �� � pkESENT BY �� 2��']A
❑ BU�LDING '
1, as owner of fhe property, or my employaes with nDDRE55
wages as their sole comoensation,will do thw wnrk nnd � tt° ' ° '2� '
Iha snucture is not in�ended or oifered for sale(Section ����TM
7044,Business ond Prolession5 CodeJ. � MOViNG TEL.. , � • �L�J,��
� t,as owner oI tha praperry,om extlusively contraUing CONTRnROR NO. • • •2�O O U
wi�h licansad conrracrors ro consrruct the projeU(Sec- - qpoREu - ' � '" " .
rion 7D44,Bustness and Professions Code). p
CONSTRUCTION LENDING AGENGY SEQBACK �ARD Hwv iOiAPROv.IINE WIDTVI O�Z 9'V S
I hereby offirm�hat Ihera is a tons�ruttion lending ogency for FROrvT 7� 2�.g a
the performance of the work for whicb this permit is issued - v.l. _ .
(Sec.3097.Civ.C.J. SIOE � • • • . •�
P.l.
lender's hloma � '
P.G Fee 5 �-5.�0 Permif Fee �'"'"R°��" I • •3 6 7 5
lender's Address � � �� r x
• n •3G'�J;,
I cartify Ihat I have read this opplication ond state Ihat fhe beuonce Fee �Q..� LDMA P/C M
obove informmlon is correct.I ogree to comply wi�h all County ,���,,,9,,;0�F�, . 0&2 9—8 8 �
ordinances ond Stote laws ralaling to bullding conshuction, To�ol Pee � � LDMn verm.M
and ha�eby au�horlxa reprefentatives of this Counly to anter
upan�3p abova-mantfoned property for Inspectian purposes.
�� // -- L-� (�- z 1./ �J SEE RFVFRSE FOR EX►IANAfORY UNGUAGE
C --Signature of Applican�,or Agent ppte �� _
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