HomeMy WebLinkAbout1285A (9) WORKERS'COMPENSATION DECLARATION � . , . � . ' . �
insore orafclertifimlelofWorkeserCompenstiooln�;a��eso'; � APPLICA�TIQN F�R� BUILDING PERMIT
o terfified copy thereof(Sec.3800,lob.C.) _ . COUNTY OF LOS ANGELES BUILDING AND SAFETY .
P❑olicyNo. Company � '
BUIIDiNG ///� Q _� � �A. .
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 `r c(sv it..G��
� �Certified copy is filed wilh the county building inspeo- eUiLoiNG. i /� .
tion department. AD�RESS � 9 � 2 LOCALItt �-�'� . 4'�-�-C�
NEAREST
Dote Applimnt � CITY / � ZIP � i CROSS SL ,
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. n55E5SOR �
� � COMPENSATION INSURANCE SiZE OF lOT NOW ON LOT � MAP BOOK PAGE PARCEL
(This seciion need nol be comple�ed if the permit is for one � �(��.p`3 USE ZONe MAP /�7 �3�/ ,
hundred dollars�5100)or less.) � . _ TRACT eiocK ioT No. / �� No. a
TEL SPECIAL
I certify ihat in Ihe perfo�mance of the work for which Ihis OWNER NO, - OT� CONDI710N5 0
permit is issued,I shali nol employ any person in any manner ADDRES �/� � � � � DISIRICT GROUP TYPE FIRE PROCESSED BY (J
CONST.� ZONE � 0.,
so as to become subject 10 the Workers'Compensation laws. �/� �� � ��� O
' /� r t
Dote Applitanl • 'L�- CITY • Z�P � STATISTIGILCWSSIFICAiION ACT. CONDO. (~J
' NOTICE TO APPLICANT: If, ofter making this C6 ifimte of � ARCHiiECi OR � � - - . - TEL. , W
Exemptian, you should become subjeU to the Workeri FNGINEER NO. CV SS NO. �/ DWEIt.UNi75 �
:Compensaiion provisions of�he Labor Code,you must forfh- ADDRESS �� � ' SEwER�na.v � a
with tomply with s�th p�ovisions or this permit sha�l be � —
deemed revoked. � TF�' ' gK, � p�, VALIUAT�ON
. CONTRACTOR NO:
��LICENSED CONTRACTORS DECLARATION � � �i�, .
I hereby affirm ihat I am licensed under provisions of Chapter 9 . A�DRESS NO. VALUATION �
(tommencing with Se[lion 7000)of Division 3 of the Business and ���. ' . . �
Professions Code,and my license is in full force and effect. , CiTY � C�ASS � S ��"r' � � � ,
� � SQ.FT. NO.OF NO.OF CHECK. � "
�License Number � Lit.Closs Size STOeiES FAMIllES OrvE • .
' - � NEW � S � .
Contractar ' Date DESCRIPTION,OF WORK .
❑ . � � � �� ADD
1 am exempt fram the licensing requiremenfs as I am a
litensed orthitett or a regizlered professional eng(neer _. _ � ALTER F�NAL
_ at�ing In my prafessional wpaciry (Section 7051. - '� �� REPAiR .� DATE �-/���5�
'� B�siness ond Professions Cade). U, OF � � �
� ExISTING BLDG. 7 �EMOL ❑ FINAL
� 8y
lic.or Reg.No. � Dore ADp�I�ANT TEI. �� , ' .
-- -- - � OWNER-BUILDER DECIARATION � . ' IPaiNr� � No.
I hereby a(firm thot I am exempl irom the Contractor's Licenze � �q���,�,�, � � ' �
_ Law for the following reasan(Sectivn 7031.5,Business and ADDRES ' !? "� � f`''"� "
Professions Coda�: Paesetii ! , p $� 2 8.5 A
_n .. . . BUIl01NG . . ./n...�.(r /�/S 0 �
`� I,as�owner of�he�croperty, o�my emcloyees wi�h qoDeE55 7"Y""�-�
woges as their sole compensaiion,will do the work and . v �' •" "�'j
�� �he structure is not inrended or offered for sale(Seaion �OCnliiY - - � -
7D44,Buslness ond Professions Code). . MOviNG �� TEI. � ��,• •2�Jr�
� � I,as owner of the property,am extlusively contracting CONTRACTOR NO. � . • •2�5 Q�
� wi�h licensed contraUoro�o consvuct��he project(Sec- qDDRE55
� -�� tion 7044,Business and Crofessions Code). - - p
RE�UIRED TOTAL SETBACK FROM E%IST. 0,�.� U��2 '
CONSTRUCTION LENDING AGENCY SET BACK VARD HWY PROP.IINE WIDTH
� I herehy affirm that�here is a conslruclion lending agenty for , FRON7 �
the performonce of ihe wo�k for which this permit is issoed P l.
(Sec.3097,Civ.C.). , - -� SiDE - �
P.L._
Lender's Name . . . , �
s Lender's Address P.G Fee E Permi�Fea �� � �
I certify�ha�I have read this opplicaiion and slare that the issoa�ce Fee ��� ' .
above informalion is correct.I ogree to comply wi�h oll Counly , Imesi�ga�ion Fee � � � � - �
ordinances and Sbte lows�elating to building conStioUion, �
and hereby ao�hori:e iepreseniaiives of this Coumy to enter Tmal Fee ,�,,;�,.J D
opon the above-mentioned proper�y for inspection purposes.
����� � SEE REVERSE FOR EXPlANA70RY LANGUAGE �
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