HomeMy WebLinkAbout1714A (10) WORKERS'COMPENSATION DECLARATION � �esurebor'afterlifko'IeofWorken'�Compensafon��=��o�a` . APPLICATION FOR BUILDING PERMIT : o�a cer�ified copy thereof(Sec.3800,�eb.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company �� � BUILDING � Ce�fified copy is hereby fomished. FOR APPLICANT TO FILL IN �5�� •S� /�(OW/} �Q�S%� ADDRE55 ❑ Certified copy is filed wifh fhe cauniy bvilding inspec- BUILDING ♦ /' ( / JR.� ��� `�`Irv f/ /y f DI�/� }�"'/ �C} tion deparfinenl. A�DRE55 /�7� ✓'`�} , Date APPlitanl � CITY ���'"lOND ���ZIP� CROSSSi. �///�OMD ,r�y,�+-.. ��'�'�J � .CERTIFICATE OF EXEMPTION FROM WORKERS' . � �. SIZE OF l0T NOW ON�LOTS nnnv BOORK r S PAGEO� PARCEI��� � �COMPENSATION INSURANCE -� � ... (This section need nof be�compleled if the permit is�for one� . - ' - . � u5e zONe MaP - _ � � hundred d611ars(5100)or less.) .-� � . � . .. - TRACT �Z BIOCK � . .� lOT NO. � � �I - NO. �. O - � . . ' � - �[9�y .7/ , SPEUAL . } I certify thot in�he performanca of Ihe work/or which Ihis O�'�NER�'/h / �gy NO. � PG - CONDITIONS � ' - �0. permif is iswed,I shall nol employ any perspn In any manner ' 9 ���k„1j}� DISTRICT GROUP 7YPE FlRE PROCESSEO BY 0 . A�DRESS/��� � �� CONST ZONE � �V w os lo become sub'ett to the Work rs' � ensat on s. /r I P ciri ?)/�H4on� ,B�RziP �'i'a- U �3 � �I` A-� p Dafe� �Applicanl � ` � ��/�'- STATISTICALQASSIFICATION APT. CONDp, ._F- ARGHITECT OR TEL. NOTICE TO APPLICANT: If, ofter making' is Certifica�e of ENGiNEEa NO. �Exempiion, you shovld 6ecome subject to tha Wo.kers' cw55 NO.�,..�_DWELL UNITS - W� Compensation pravisions of the La6or Code,you mvst forth- pDDRE55 � SEWER hua � ith comply with suth provlsians or this permit shall he TEI. — deemad revoked. . � CONiRAC70R �"�^"�� eK. rG, � VALIDATION LICENSED CONTRACTORS DECLARATION � �i�, I hereby affirm thal t om�icensed�nder provisions o(Chopter 9 ADDRESS NO. VALUATION - ��� (mmmencing with$etlion 7000)of Divisio�3 of the Business ond ��C / � ' Professions Code,and my license is in full force ond effect. C�Ty �LASS E , � ����D 5 ORI�ES F MI�ES CONEK Licansa N�mber lit.Clasi SIZE NEW � E DESCRIPTION OF WORK � Contractor� Dafa . . . . ❑I am eXempt vnder Set. � ' �T�� � �� A� / � 1 q�7ER � FI AL �CQJ- � � U E � � . . . . - 8.8P.C.for this repson - REPAIR USE OF �EMOL � Data: EXIS7ING BLDG. - ❑ B $Ignafure � A�P� A��hY�� s� 'D�� TEL. /[/ ' � Y OWNER•BUILDER DECIARATION IT /w I hereby ai(irm that I am exempt from the Conlrattor's Licensa qDDRE55� Y�o�� /��� eK��`�^ � Low(or the following�eason(Section 7031.5,Business and � - - � $� 7�,Il�� �� -Prof ssions CodeJ: � pqE N # � . , 9UIlDING • • • I, as owner of the properly, or my employees wfth nD�RE55 � � � . . . / � wopes as Iheir sole tompensation,will do thw work a�d �� TM �'• •3 O,Jr� - �he strucrore is not infended or offered far sale(Secrion , 7044,B�siness and Profess�ons Code). . 1v�OwNG TEt. • • •J Q Jr Q v ..� I,os owner of the properry,am excluiively confracting NTRACtOR NO. wiih licensed controctors to consir�ct tha project(Sec• qoDkESS ' 0�,2 6—$5 �ion 7044,Business and Professions Code). . . ' REOUIRED TOTAL SEIBACK FROM EJ(IST. CONSTRUCTION LENDING AGENCY SEi enCK YARD Hwv PROP.uNE WioTH ► I hereby affirm tha�there is a consrruction landing agenq for fzoNr - - � - �- tha performanca of the work for which�his permit is Issued P.L. � . iSet.3097,Civ.C.�. SIDE , . . . P.L . . _ . . . . ._ . lender's Name � P.0 Fee f Permit Fee �4'� lender's Address � - � I cenify�hot�l have reod Ihis applimtion dnd stme�hot�the� � Issuen<eiea �� � � � obove informorfon is torreU.I ogree�o comply with oll County Invesrgation Fee ` � ordinances and Sra�a laws relating�0 6ullding tonstrucfion, To+al Fee ��� ,�v � � � 6nd hereby a orize represematives of this CouMy to enter , . upan t e o �b-mentio ed pra fy for inspection porposes. � � . ___.. V { �6 � SEE REYERSE FOR EX�IANATORY IANGUACE /` ' na�urdof Applicont Agenl� e . •� ' � ' . . - . `" ,. 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