HomeMy WebLinkAbout1310A WO�KERS'COMPFNSATION DECIARATION � - � � � �
I here�qy ofFirm�ihol 1 have a certi{icote of consenl to self �
insure,orarer�iiicateofWakers'Compensalion��,��a��e, � � � APPLICATION FOR BUILDING PERMIT
or a certified topy thereoF(Sec.3800,Lab.C.� COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
PolicyNo. Company ' ..
� Cerrified copy is hereby forntshed. FOR APPUCANT TD FILL IN BUIIDING
ADDRE55 O -3 ��✓� /4- •
� Certified copy is(iled wilh�he counly building inspec- - BUnDwG �
tiO�department. . ADDRE55 i0.53 S. LoNc-�d��w pr2. ,
Date -APPlitant .. CIttV1A'���� � � nv 9�7�5 �ocnurv
CERiIFICATE OF EXEMPTION FROM WORKERS'- � - -- � - . NO.OF B�DGS. �. . . NEAaEST ,. . . �
� COMPENSATION INSURANCE � SiZE OF LOT NOW ON LOT CROSS ST.
(This sec�ion need not be completed if�he permit is for one . ASSE$SOR
hundred dollors(E��)or less.) TRACi BLOCK � LOT NO. Mqp 9(SplC�� PAGE PARCEL
I cenify that in ihe peiformonce of tha work fo�which this y�
- OWNERV'C•�M�S '.'1 ��F�Ut''-'TlEO. � !J �,pP -.�—.�3 �•'
permi�is Issued,I sholl nol employany person in any manner pDDRE55 Iv� y �'�aCv��w ���• S���A� - �'
so as to becoma sobject lo the Worke�s' ensallon Lows. � ,�r� � CONDITIONS U
Date � g �APPlimm , . CiTY D�MON� ,.N 2iP g"�7`�-� �
ARCHITFCT OR, 1, TEL � y� �C DISTRICT GROUP TYPE FIRE PROCESSEO BY O
NOTIC iQ APPL CANT: If, ofter ma is Ce ifimte of ENGtNEER v�C" n�� NO. :.FJ�'2�'�7 - CONSy, �ZONE V
Ezemption, you should becoma s�blect to the Workers' � n`,� p� �` � .
Compensaiion p�ovisions of�he lobor Code,you most forth- ADDRESSlr������ T�LVV�����v� �V . 3 �> � a
with comply wilh such pravisions or Ihis permil sholl be TEI. STATISTICAL CLA551FICATION APT. ONDO. Vl
deemed revoked. . . . . �ONiRaCTOR ����+ V��-��No. Z
IICENSED CONTRACTOR$DECLARATION.. . . , . ... . .uC, . M55 NO.�DWELL.UNITS ' �
� I hereby aHirm that I am licensed under provisions oi Chapler 9 ADDRESS � NO.
- (mmmencing wirh Section 7000)of�ivision 3 of the Business and �i� ��R'�'0.P
Professions Code,and my license is in full forte ond effect. � CiTY � CLASS BK � VALIDATION
' � � 50.FT NO.OF NO.OF CHEIX .
License Number Lic.Clase � SRE � $TORIES � FAMtUES ' ONE� . .
�j,,,^ VAIUATION
�ESCRIOTION OF WORK.�(�v � N� ❑ �^ /► �
Contiactor ' - Date � � ADD � S K�C 6O�
❑I am exempt under Sec. �L� �M T 2 '- ,
AITER � i
8.8P.C.(or ihis reason REPAIR � s �
� Dare: - USE OF �1 "1 3 1.0 R
EXISTINGBLW. ��f�L�,T�L DEMOL ❑ _
5'�natvrn�___�Lu/l�^ � APPtICANT TEL. �• • • • . � .
FINAL �7
OWN�ER•BtfDER DE�LARATION PRINT NO. DATE oc'Z��9D . _
I hereby affirm that I am ezempt from fhe Conlrocror's license � � � � � - ��• 1 6 S G 0
low ior the follawing reason(Section 7071.5, B�siness and ADDRE55 FINAL , �
Professlons CodeJ' �� - � � � � -�� � PRE NT � - �� � 'eY ' . • � � 6 E Q�"�_%
� BURDiNG , ,, ,
I, as owner of the property, or my employees with aDDaE55 �O C�_f A.
wages as their sole compensation,will do tha work and � � � � ' �
�ha struuure is not intended or offered for sala($ettion ����T� � , -
7044,Bus�ness ond Profess�ons Code). MowNG� � iE�. . - - ' ` ' . - . .
� I,as owner of tha p�operty,am extlusively conlracting CONTRACTOR NO.
with licensed conhacrors ro constrotl the pro�ecf(Sec- � qoDRESs �
tion 7044,Business and Professions Code). � �
� �-- CONSTRUCTION IENDING AGENCY - � � SETQBACK YARO HWY r�rAp OP.L�NEF W�DTH -
�I hereby affirm thal Ihere is a construction lending agency for . ppONi � . . �
the performanca of tha work for which Ihis permit is issued .. P.L. - . . •- . -
(Set.3097,Civ.C.). SIDE . -�
P.L. - � - ...
Lende:s Noma - � �
�s� f� LDMA Ref.# .
. . .. . P.C.Fee S Permit Fee J '
Lender'sAddress � '�
I cartify t at(have read this applitotion and slote thal the ._ � lasuonce Fee . �•� IDMA P/C M .
abave inf rmat' is correct.I agree lo comply with oll Counry �meseigoNon Fee o �
ordinan o 5 ta laws reloting to building construction, Total Fee /� O i U� IDMA aerm.N . . .
� and he � rize r resenfotives of�his Coumy�o enter � '
upon t e ty for i�spec on p�r oses. �
� r ` Q SEE RfVERSE iOR E%PLANATORY LANGUAGE ' �
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