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
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