HomeMy WebLinkAbout1484A 1485A WORKERS'COMPENSATION DECIARATION � � ' �� � ---' ' - -- "" ''� � � � � � � -� � � �
I hereby offirm �ha�I hove a�e,f��,�o,e o,tonseM fo=e�� � � � �� �� APPLICATION� FOR BUILDING- PERMIT �
insure,or o cer�ificore of Workeri Compenso�ion Insurance, .
osa cerr(ied copy ihereof(Sec.3800,tob. .) . COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polity No��mpany
� Certified copy h hereby furnrshed. FOR APPLICANT 70 FILL IN eW�owG O Q Q
ADDRE$$ J
rJf Certif�ed copy is filed with�he county build�ng inspec- � BURDiNG � �
�l lion de arfinent. AODRE55
Dare_���Applicam�LUfMC�C—���. CITv ZIP IOCAIITY � �1
E TI CATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. NFAREST �,�``^_ ��`
COMPENSATION INSURANCE SIZE OP LOT - - -- NOW ON LOT � � CROSS ST. N��.r�
(This settion need not be tompleied if the permit iz for one �RACT � BLOCK LOT NO. auESSOR
hundred dollors(EI00)or less.) � � � 1V1Av 600K PAGE PAR�L
- � � 1E1. USE ZONE NAF
I certify Ihot in the performance of the work ior which ihis � OWNER NO. � �. C a __
permit is issued,I shotl nol employ ony person in ony manner SaECinl O
so as lo become subjett lo Ihe Workers'Compensolion Laws. ADDRE55 CONDITIONS U
Date Applicant . . . ,�: CITY ZIP .S O
NOTICE TO APPLICANT: If, after making this Cerlificate of ARCHiiECTOR iEl. DiSTRiC7 GROUP ttPE FIRE PROCESSEoeY �j
ENG�NEER NO.
E.emptian, you should become subjecl to Ihe Wo.keri CON ZONE W
. _
Compenso�ion p�ovisions of thc Labar Code,yoo must forth- qDOaE55 � �� �� � Ci� �
with mmply with soth provisions or this permit shall 6e ( -
deemed revoked. ' � CONTRACTO \ � N�' STATtSTICAI C1A551FICATION APT. CONDO. Z
\
IICENSED CONiRACTORS DEGLARATION � tiC. Ctq55 NO.0•1 Dwetl.UNRS
I hereby afiirm 1Frot 1 om licensed under provislons of Chopter 9 ADORE p, -
(commenting wilh Section 7000)af Division 9 of Ihe Business and ��� SEVhR 1�V . ,
Rofessions Code,and my licrose is in lull force and effec�. -- CITY � 55 �� � � gK ,, �. VAU�ATION
����.(� 50.f NO.OF NO.OF CHEGK
license Number�-r?����� Lic,Class� � 512E STORiES FAMIUES - ONE � � �
�} V 1 VALUATION
Coniroc�orl�.��ZmL1,�l�Oflt�are _ __ oeseei io OF WORK � N� ❑ S ���� .
ADD
�1 am e�empt under Sec. � —1- '1{�yp ❑ .
a Autlt'
B.BP.C.fo�this reoson r`^� Q ,CQ�i � � REPAIR � _
Da�e: USF OF . _ . _ . ._ . DEMa ❑ . . .. _ . �� Q��1 P
E%ISTING BtDG.� r
.Signoture APGLICANT . . . � T FIN L,� ' ��e • • •2 J
OWNER-BUIIDER DECLARATION CRINT� �� D YE �
I here6y afiirrtl Ihot I am axempt from the Conlractoi s license - �- -��� SL,L.'S '�S e\,1Q �• � I ' ���O O
Law fo�the following reason(Section 7031.5, Business and ADDRE55 FINA
Rolessions Code: ' 6 =
) . . . . . _ . . PRE ENT _ . . . _ . Y � —� � � �2�GO c.:�
� BUILOING
I, os owner of�r,P prope�ry, or my employees with ACL`R:SS V 9�Q`7—O O
wages os�he�r sole compensation,will do�he work and '
the srructure is not imended or offered for sale(Section ��`��TY ' �,� 4��� .
7044,Bustness ond Professions Code)._ . MOVING TEL � `
� I,as owner of�he property,am exclusively comratting CONiRnC70R � - -� - � NO. � � � #� � � � � �
with Ikensed conrroctors ro construct the project(Seo- pDorre55
tion 7044,B�siness and Professions Code). � � • •3 6 7 5 �
CONSTRUCTION LENDING AGENCY . SE�BnCK YAR� HWY T��Ap�P�NEFR- WIDTH - - � ��
I hereby afFirm thot there is a tonshuction lending agency fo� � FRONT � � �3�7�
fha performance oi ihe work ta whith this pe�mit is issued . a.�. - � � - O 9.O 9-H H
(Sec.3097,Civ.C.). �- � Si�E
P.l.
lender's Name � �� �
C LDMA Ref.M
lender's Addrcss � - _. . P.C.Fee f Perm�i Fee � . , � ,
1 certify that I have read this opplicatlon and stole that the �ss�ance Fee { LDMA P/C N
obove in�ormation is corrcct.I agree ta tomply with all County ��� Investigo+ion Fee � �
ordinancez ond Stale laws relaring ro b�ilding construc�ion, io+al Fee i�hte,ve.m.M
and he�eby authorize represenlaiives of ihis Counfy ro enier � - -
u n�he ove-mantioned proper for inspeclion pvr os�
�r ,��^ A O 0���� $ SEE REYERSE FOR EX�LANATONY IANGUAGE
Signat�re af Applicanl ar Aqenl �o e .
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