HomeMy WebLinkAbout1096A 1097A WORKERS'COMPENSATION DEQARATION �
�hereby offirm�hot I hove o terfifitale oE�o�;e��,o se�f � � ��.�APPLICATION� FOR BUILDI NG �PERMIT �
ins�re,or a certiiitota of Workers'Compensation Insurance,
or a certiiied mpy the�eof(Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUIIDING AND$AFETY
Policy No. Company '
� Certi(ied copy is hereby fumished. FOR APPLICANT TO FILL IN BURDiNG r
ADDRESS �3 d V �• n`/
� Gen�f�ed copy Is filed with the munry buildtng inspeo- gui�oiN� /� �� � /J
tion deparlmenf, ADDRE55
Dale�'J'�Applican � CiTY /1l�r/4� Ziv �OCntITY
CERTIFICATE OF EXEM ION F` WORKE ' NO.OF B�DGS. . NE4REST
COMPENSATION IN ANCE 512E OF lOT NOW ON tOT CRO55 ST. - ' --- -� -
(This Setlion need nat ba comple d if Iha permil is fo�one TQACT- '3 BLOCK LOT NO.� ar-l� ASSE550R
hundred dollors(E100�or less.) MAP BOdC�' � PAGE PARCEL
TEL. f USE ZONE AMP
I cer�ify fha�in the performance of the work for whfch this OWNER U/3 ,r� NO �_' �. '�—3a,
permit is is:ued,I shall aot employ ony person in ony manner ' �� SVECiAt �' --
so as to become subject to the Workers'Compensation laws. - ADDaE55� _c CONDITIONS. 0
Date � Appiimnl CITV �r ZIP (�/A� �4s � �
ARCHITECT OR TEL.
NOTICE TO APPIICANT: If, offer making�this Certificafe of DISTRICT GROUP ttPE FIRE RtOCESSEDBY O
ENGINEER NO.
Exemptfon, you should 6ecoma subjecl 10 Ihe Workers' � ' �7� CONST.!' l� 20NE /, r F—
Compensation provisianf af the tobor Code,you must(orth- � K.3 —1� 3 �Vl/I a
wi�h com I wilh such rovisions or Ihis ADDRE55
py p permit shall be TEL. STATISTICALCLASSIFICATION � APT. CONDp.
deemed revoked. �oritenaoR /�d G -v No. � _ � � q/ Z
IICENSED CONTRACTORS DECLARATION .� . ,�,�j i��, QASS NO.�DWELL.UNITS �
I hereby oHirm Ihol I om licensed under provisions of Chop�er 9 ADDRE55 y.�q. �.Y. NO. //�3-
(commenctng with Setlion 7000)of Divizion 3 af tha Business and � ` ��� ��R�P
Prafessions Code,ond my license Is in full force and eHect. � � -� CITY �l�//y2 �Y� /�/��7r �IASS /�- . . � WLLIDATION
Sp.FT. NO.OF NO.OF CMECK BK. PG.
Li[ense NVmber Y��3�� LI[.Clcss h- � SIZE � STORIES - - FAMtlIES� �"�- - ONE , .
� r Q VALUATION
ConlroUo�v.T/�Dote'�';"d� � DESGRIPTIONOFWORK N L � NEW . s � �.-�—� .. .
ADD
❑1 om exempt under Set. d f �- /G ' , - -
L �v . AUER
� B.BP.C.(or lhis reoson � . . ,-/j'I/O G.d a' REPAIR,❑ s � .
oate: . - useoF �'�� .°1 G 9.6 A
EXISTING BIDG. � a ❑ �� � e �7�
- $(9n01urG . . - . . . . . .. APPLVKAM � U/� /fLl/GDG NO. �.•771f FINAL l I2P 6� � I-• •�2�I.G i]
OWNER-BUIIDER DECIARAtION ' DATE �
�here6y aiiirm that I am exempt from the Contmc�ar i Limnse � "� -- �}"f � '� • ° •!7,E'J=
Law for the followin9 reason�Secfian 7031.5,Business and aDDRE55 N� �d ♦ /YZ � �Ad�: FlNAL ' -
PfOfes5i0n5 CoCIe�: ' � '- ' - - - - - -� PRE ENT � By �i� ��Q'��,�7{
❑ BUIIDING I�• •�1�.A V� '
I, as owner of tha pioperty, or my employees with nDDRE55 � �
wages as their soie cempensation,will do the wcrk and � - � �� - �'
the structure is not intended or oifered for sole(SeUion ��`��TY � � f<<_���.` • • •t!,�i.Q 0��
704a,Business ond Professions Gode). � � MoviNG - - � - � � TEt. - �� ''b` 0 23�3_a 7
'J.�
� I,oi OwnGr of Ihe properfy,am exclusively confraCfing CONTRACTOR NO. _
wilh licensed tonfroctors to constrocf Iha projecf(Sec• � � ADDRE55 � � - � - �
rlon 7044,Business ond Professions Code�.
CONSTRUCTION LENDING AGENCY sE�BACK �ARD �+wv TOTP'pROP uNEFR WiDTri �
I hereby affirm Ihaf Ihere is a const�uttion lending agency for FRONT
ihe performance oi ihe work for which Ihis permil is issued P.l. _ .
(Se[.3097,Civ.C.). SIDE � . �
P.l.
lender's Name � �� - � -
r.e.F��s a � �3. P�,m,�F�s 3�.S� io�nn aer.x
Lender's Address � �
I certi(y thal I have read Ihis application and state thot the lesuance Fee �r SC� LDM4 P/C N
obove information is torreN.I agree fo tomply with all County Invesrigo�ion Fee
o�dinances ond Srate lawe relming lo boilding canstruction, _ Toml Fee •� v '
ond hereby nuthorixe rep.esenfotives of this County to en�er 3 LDI�M Perm.N
upon�h bova• r�t�ed property for inspettion purposes. '
�f/ / '� � SEE REVERSE fOR E%PLANATOIIY IANGUAGE . �
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