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Home My WebLink About1736A (17) WORKERS'COMPENSATION DECLARATION� � ;'., I hereby afiirm that I have o certifitote o��o�,e�„o se�f APPLICATION FOR BUILDING PERMIT � ' insore,or a ce�tifica�e of Workers'Compensoiion Insu�ance, , � ar a cer�ilied copy Ihereof(Sec.3800,Lob.C.) � � - COUNTY OF LOS ANGELES BUILDING AND SAFETY � Polity No. Company � � � BUILOING / Ce�rified copy is hereby furnished. FOR APPUCANT TO FILI IN nDoaE55 / �'`' r`- i ' `�. � � Certified m s filed with the couni build�n ms ec- �� Py� y 9� P BUILDING �' �1�' GD N� C . lion deparfinent. ADDRE55 7� � , Da�e Applimnf CI7V �� Zlv �p�q�iTy �� !.,_�_: i{�_ NO.OF BLD NEAREST � + CER7IFICA7E OF EXEMPTION FROM WORKERS' . � /�, n COMPENSATION INSURANCE SIZE OF l0T NOW ON LOT CRO55 57. �I'�i-� l�t�.., �t�r,,,4�.1.}� (This section need not be comple�ed if the permit is for one TRnCt �� `� e�oCK iOi NO.I i �' '�ESSOR � hundred dollars(E100)or less.) ' "'� TEL � MAP BOOK PAGE� ~PARCEL p}.'� � OWNER� lC FiE TI� NO.� - � USE20NE �P /I)(/�� ,� U I cerlify Iha�in the performance of the work(or which fhh Y �_ NO. r � permit fs iisued,I shall not empioy any penon in any manner ApoReSS 3c�S� '70 h//� ,r . ' p��('U �E��A� •� r -�wj . so as to become wbject�o ihe Workeri Compensalion Lows. �/ CONDITIONS un , ,./�� 1 i. CITY �N U F 21P � ^7 . � w Date Applicont ARCHiTECT OB TEI. � � NOTICE TO APPLICANT: If, ofier making fhis Certificaie o{ � DiSTRIC7 GROua ivpE fIRE PROCE$SED 8Y ENGINEER NO. ¢ Exemplion, you should become subject to the Workers' ' CONST. ZONE +� a Compensafion provisions of ihe Lobar Code,,you mus�forih• qD�RE55 � y '�`.�-' � l.. a wi�h comply with such provisions or this permit sholl be 5� tEL ' STATISTICAI C1h551FICATION APT. CON�O. '� deemed revoked. �ONTRAROR !� , ,Y� NO. ., LICENSED CONTRACTORS DECLARATION p�, . CLA55 NO.� } DWELL.UNi75 F- . I hereby affirm Ihat I am licensed under pro��sions of Chopter 9 AD�RE55 NO. ��R�P (commencing with Section 70W)of Division 3 of the 6usiness and UC. :, Prolessions Code,ond my licensa is in full torce and effect Citv � ' CtaSS � BK � YAIIDATION � SO.FT. l NO OF NO.OF CHE()( Litense Number Lic.CIaSs SIZE ��✓ STORIES FAMILIFS ONE :�..�.,�,.�.,��7l VAWATION � ' " DESCRIDTION OF WORK r NEW F:.!,! !;�,�,�, Contractor �afe A�D s r'��"?�'�� i!!,�5[��!,t ��am axempt undar Sec. �J� C � �' � '• ALTER � •o�`,Gy�%��.' e.8a.c.fo��his reason G G if� / .ZD RfFA1R S � f, . , Dale: F%STNG BLDG. � �EMOL ❑ A��[.S,��i lj,�, � Signoture F.vPLICAM iEl. FINAL � OWNER-BUIL�ERDECIARATION vRINT �� I FL� C/� NO. �u� �%C% DATE I hare6y offirm�hat I om exampt irom the Contractor i Licanse �� ^!�'G'pN� /'T• � . Low for the following reason(Sec�ion 7031.5,Business and ADORESS c' l FINAL Professions Code)� p By ' � ❑ BUILDING 1, as owner of the property, or my employees wifh ADDRESS woges as thair sole compensation,will do Ihe work and .�J�`��' �he strunure is not intended or offered for sale(Secfion tOG4u7Y ' �� 7044,Business pnd Plolessions Code�. MOVING TEt. , �. � I,os owner of fhe properfy,om axclusively confracfing GONTRACTOR NO. ' wifh litensed controUars b construcf Iha projetl(Sea ADDRESS � ��V • � tion 7044,Business and Profeseiona CodeJ. , CONSiRUCTIONLENDINGAGENCY SET�BACK Y!RD HWY TOIAPROiP"rKE WIDTFI l hereby affirm thm there is a construUion lending ogency for FRONT Ihe per/ormance of the work for which�his permil is issued P.L � � (Sec.3097,Civ.C.). SiDE P.L " Lendar's Name � l LDM4 Ref.N Lender's Address � � P.0 Fee S Permu cee � fi. �-� , �, �� I certify that I have read this appiicotion and slale lhat tha Issuancr fee I �� '� �� IUMA P/C M above informafion is correcl.1 agree io tomply with all tounty ' Inveargm�on fee ''7 � � ordinances and Srote laws relaiing la building mnstrvcfion, Totol fee� � ' / � tDMq>erm.M � '' . and hereby outhorize represaNatives of�his County fo an�er - �. upo/n Iha abova-mentioned property for Inspec�ion vrposas. , � . . /i s'%�//�/..✓/�� /�J/S/�./1 ��/y SEE RFVERSF fOR EXPlANA70RY UNGUACE �� - Siynanre of Appli<an�or Agen� pore ;- .. , _ , .' ' _ ." . _ . ,. , ` .. � , ,_ . _ . _ _. _. _ _ __ . ; '' ' :: ' , . i ;_. . .. , --- . _ _ __ _ _ t .". : .. ;