HomeMy WebLinkAbout1398A (7) WORKERS'COMPENSATIbN DECLARATION � � � �
insua66rafcertifca'teofWokes'�Compesalionlnsu;e��" . APPLIC�TI-�N���FQR�: BUILDING PERMIT - -
ar a cer�ified copy rhereof�See.3800,Lab.C.) COUNTY OF LOS ANGELES_ BUILDING AND SAFETY �
Policy No. Company � BuitDiNG
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN n�oeess �L���
� Certi(ied copy is filed with fhe counry building inspec- BUUDiNG �. �
fion depoilment. ADDRE55 � 1 W� LOCALITY
/'��� � 2..n NEAREST '
Data - Applimnt CiN QJ C3Q� 21P CROSS S7.
CERTIFICATE OF EXEMPTION FROM WORKERS' � � NO.OF BLDGS. ASSESSOR
COMPENSATION INSl1RANCE SIZE OF LOT NOW ON lOT - MAP BOOK PAGE PARCEL
(This sectlon need nof ba completed if the permit is for one � . � USE ZONE MAP /�
hondred dollars(5100)or less.) . ianci 1��5.� gLpCK � . � LOT Np. �' NO. TJX� 3
' qI y /�� ' A-� TEL' SPECIAL
I certify that in 1he performance of tha work for whith this OWNER '4'\��C W�u� NO. -�^�a'� r CONDITIONS a
perm�t is issued,I shall nol employ any erso in an � . . .. DISTRICT GROUP TYPE FlRE PROCESSfD 6Y �
ADDRE55 UI C���S CONST. ZONE U
_ so as ro be ome ubject to the Wor pe n Laws. n, ` �,�y� ,
��1�� lX V�--� .d U—i -� C
Dafe �� Applico t � ' ��— CITY �P STATISTICAL CL45SIFICATION' APT. CO DO. p
NOTICE O A PUCANT: If, a e mo ing ' Ce icote of ARCHITER OR . tEt. � - V
Exemptlon, yo� shou�d becoma subje[f f e Warke�s' ENG�NEER NO. CLN55 NO. �WELL.UNITS w
Compensation provisions of tha Lo6or Coda,you must Torth- qooREss SEwER nMP �
with comply with such provisions or this permit shall be /�� 7EL. �
deemed revoked. �pNTRAC70RL(J ��NO. BK. - PG, - - VALIDATION �
LICENSED CONTRACTORS DECLARATION t ., - ul�i�,
1 heraby offirm that I am licensed under provisions of Chopfer 9 AD�RES �W ,� 2L71 NO. 3 VALVATION - �
(tommencing with Section 7000)of Divislon 3 of the 8usineu and �-`__f �+ ���. O� .
Professions Code,and my license is in full force and effect. �iN /�"!�\eS `j��,qs�—{�� E ,
� ��� $Q,FT�'.9... NO.OF N .OF CHECK ,
License Nomber �lic.Clase size 4"+v ST02IE5 FAMILIES ONE
�1A�,�jp�zae u1 � _ N� � s
CAMrOCfOr S'^Ed� pa�e� DESCRIPfIONOFWORK
❑I om eaempt unde�Sec. 1C �^h'16F� 4� � a�o._. ❑ c"1 3 9.8 R
- -R�'�T'YI MN�O ALTER � FINAL . . .
B.BP.C.fol tlti5 reason . � � � REPAIR � DATE �• . • • e ,�
' USE OF � BINA -
�1e' E%ISTING BLDG. �EMa y � � e�J 6.7 Jr
Signa re � APRICAM TEL. ..
E -BOIL DEC ATION � FRINT NO. _ � Z,'r�o � •3�,7 5�
I hereby irm that I am exemp 4 tha Contrac�or's Licensa �(�
law for ihe following reason(Sec�ion 7031.5,8usiness and - ADDRE55 -� �- -� ��
os�s—ab
ProfessionsCode): � pRE ENi '-� . .
❑ BUILDING , ,
I, oe owner o(1ha property, or my emplayees with ADDRESS �
wages as iheir sole tompensation,will do�he work and .
_ _ 1he strocture is nat intended or affered for sale(Sec�ion , ����TM .. . . .
7044,Business and Professfons Code). MOV�NG TEL.
� I,os Ownef o�tha properfy,om extluslvely controcling , CONTRAROR NO.
.._.. ....... . . . .
wilh litensed contractor:to constrvct the pro�ed(Sec• I qDORE55
�fion 7044,Business and Pro(essions Code). . ..
REQUIRED TOTAlSETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY � SET 9ACK YARD HV✓1' pROP.LINE �✓IDTH , -
I here6y n(firm that there is a construc�ion lending agency(or pRONi . � .- ���. ... . ... . . . .
the performonca of the work for which this permi�ia issuad � p.t. � .
�Sec.3097,Civ.C.J. . � SiDE -
r . .. _ _... _ . . .. . .... .. _ . .
P.L.
lender's Nome �
. . . . .._. .... _ . _.... .._ . . . ._...
Lender's Address , �.C.Fee S Permit Fee �-�
- I ce�tify ihat I have read lhfs applicolion and sta�e thot the � �� he�ooce Fe� ��d� s�
above information is correct.I ree to tomply with a�l County Invea�igoiion Fee �
ordinonces and 51ote la relaY g fo boilding consMutlion, � � � ---�6�7� � �' - �� � " �
nnd ha iz e r atives of fhis County f enter To+al Fea
up m ' ned properry for inspedion p pose. � � � � � - �� � �� - � - �
� _!_�' � " SEE REVERSE FOR ERPLANATORY LANGUAGE � '
�gnofure o ppli nt or Agenl po�e . ... . . . .�..V. ...... . . . . . . . ..��
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