HomeMy WebLinkAbout0949A (5) WORKER$'COMPENSATION DECLARATION �� � � � .` " "-��--� - �' "��" -� "�' � � -
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I hereby offirm iha�I have a cenificate o(consenf to=e�F ����� qp�p�ICATION - FOR �BUILDING PERMIT �
insure,ar a cerlifica�e of Workers'Compensolion InS�rance,
o�a certified coQpy ihercetojF(Sec.38 ,Lab.C.) ,,�/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polity No. 1 ��7 aCompony ��. 'rG �,i �
� Certified mpy is hereby furn�shed. FOR APPLICANT TO FILL IN BUILDING
ADORESS � �
� Certified copy is tiled wiih ihe tounty buiiding inspec- BunDiNG ( - � �
tion department. (� ADDRESS ) � (y, T(�
Dote •(i "+D Applicanl , `�r� CITY Q LP I 7 ' IODUTV
CERTIFICAIE OF EXEMPTION FROM WORKERS' •,. NO.OF BLDGS. _ NPaREST -
COMPENSATtON INSURANCE SIZE OF lOT � �� � ��� NOW ON LO7 GROSS SL �� -- ��-.
(This section need nof be tompleted if Ihe permil is for one ASSESSOR
. hundred dolla�s(E100)o�less.) � iRnCT - BLOCK LOT NO. � � p�qp gppK 7AGE PARCEI �
� TE�' USE ONE M-4P
I certify�hat in ihe performonce of�he work for which this � OwNEtt. NO. ��I �,p. ' �3 a ---
permit is issued,I shall not employ any pe�son in any monner A,/n SVECIAI c O
� so as�0 6ecome subjetl fo fhe Workerz'Compensafion Laws, - ADDRESS �/l% CONDITIONS � `J'�' U
� � - CIN ZIP � �
Uate Applimnt � �
NOTICE TO APPLICANT; If, ofrer moking Ihis Certifitale of ARCNiTECT OR TEI. DISiRICT GROUP ttPE FIRE SSED BY
ENGINEFR NO.
Exempfion, you shou�d 6ecome subjet� to ihe Workers' . . /� CONSi � ZOtaE �
Compensaiion p�ovisions of the Labar Code,you must forth- qDDRE55 (%�� N
iih comply ih soch provisions or this permit shall be TF�
deemedravoked. - � . ' "" � �� �"" � 'J�4 Jlq��S$ STATISTICAtCIASSIFI ATION APT. CONDO. Z
. CONTRACTOR NO. —
UCENSED CONTRACTORS DECIARATION �� �a � `��� ��� CLAS$NO. DN/ELL UNI75� � � ' �
1 hereby offirm thot I am licensed under provisions of Chopter 9 -' A�DrtE55 [i o�J No. 1 -
(commencing wiih Section 7000)a/Division 3 of the Bustness and n ��� /� SEWER MAP
Professions Code,and my license is in full force and eflect � [itt Y - MSS l.'��o - BK � .- VALIDATION '
50.FT. NO.OF NO.OF CHECK
�i�e�Se Nu be� �L4310� �;�.��as, S�ZE. � STORIE$ � FAMItIES�� ONE
1/ �1�1p(ff7 NEW VAWATION OJ � c'G�J��>'A
CoNraC�o W Itl�o�e 1'L7'DJ - . DESCRIPiION OF WORK S 10� �� _
IUI�R.�l�G A�D : , �I • �°�3
�I am exemp�UndBI$CC. � „ AITER ' �
B.BP.C.for Ihif reason � � REPAIR � s . I • •�4�C
a�e: USE OF � DEMOL • ^ � T
E%ISTING BIDG. ❑ �l.1 J�J��
Slenelure /��` � ....-. ACPLICAfd(� iEl. !..'
CRINT � � NO. / — � FINAL O 7.2 9—��
O NER-BUILDE DECIARATION DATE
I hereby affirrrt�hai I am exempt from the ComraUoi s License � � � � � �
Law for�he following reoson(Section 7031.5,Business and ADDRE55 FlNAL �
Professions Code): , . . . F�E ti .. .. .. . BY � � � �
OBUILDING
I, os owner oi the properly, or my employees with ADDRE55 ' n I
wages as�heit sole compensalion,wiil do the work and . .. . ._. .. . . . y �
the slr�tt�re is nol intended or oifered for sale(Setfion ����TY �� �
/',_ J
7044,Business ond Professions Code). .. , . MOwNG . _ _ . TEI. ,. � Q} ��� �
� I,as owner of tha property,am exclusi�ely contracting CONTRAGTOR NO. V �
with licensed conrracrors lo constroct tha project(Sec- . . AD�RESs � �� - - � � - - � --� �-� ���\7 l ,n„� � ��
tion 7044,B�siness and Professions Code). 1.� � ��� �
CONSTRUCTION LENDING AGENCY .... SEQeaCK YARD HWY TOTAP OTP.LINE � W�DTH ��\ A�. V � � -
I hereby affirm thai there is a construc�ion�ending agency for FaONT J; �
rhe periormance of Ihe work for which Ihis permit is issued p.L. 0
(Sec.3097.Civ.G.)• � SiDE . . .
P.l.
lender's Noma � � '
5 _rr1 tDMA Re1.M
lender's Address - � . . a.G Fee�S a C7 V Fcrmn Fee � _ , .. ' . . .
f certify�hat I hava read this opplication and sfata that the I�evonce Fee IDnM v/C M �
obove informolion is correcf.I agree la tamply wilh all Counly � �nvestigo�ion Fea
ordinances and Siate laws rela�ing lo building construclion, Taol Fee LDAM Perm.N �
ond hereby outhorize represenla�ives of this Counly to enter � �
upon tha 4�va•menli d pr erty for inspection purposes.
�� 1� �� ,�29•� SfE REVERSE fOR EXPLANATORY LANCVAGE .
� SIgn�Appl;<anl or Agent po�e . '
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