HomeMy WebLinkAbout1410A (7) � WORKERS'C4MPENSATION DECIARATiON �
1 hereby uffirm that I fiove a cerfificate of consent ta self ,�,Pp`re�►�rion�� Fo� su«�i�G PERnniT
inswe,or o ceilificate of Workers'Compenaolion tnwrnnce, -
or a certified copy rhereof(Sea 380f?,lob.C.) - - �
COUNTY OF l05 ANGELES BUILDING AND SAFETY
PolityNP .. � Company- BUILDING
O Cer�ified copy is hereby fumished. f�QR APPLICRNT TO FILL IN `,�j /(f
A6DRES$ �
aCertified copy is filed with the tounty building in�eo- gU1tDMIG . /�
. .tion deportmenl. ADDRESS LOULItt ./7.
. . .. '.._-.. ._ ..- [� �i� NE4REST
Dale . ... . Applimnt � Cm' ZIP '1� t CROS55T. . .
CERTIFICATE OF EXEMPTION fROM WORKERS' ���a��s• AsS�ssoR � �
COMPENSATION WSURANCE SizE°F aT n�ow ON�Ot nuv soou race v,nricE�
(ihis section need not be completed if the permit is for one USE ZONE- MAP �'eS-
hundred dollwc(3100)or lau.) r�R � �S BIOCK t0T NO. � . N . ��' �-Y
_._.. . __.. ._
" '_'
. . �- TEL _ ________ . .___._
I[ertify ihat in the OWNER ( {� f NO. Y CIN�IDIilONS d
performance of the work for which this _ . DISTItiCT GRIX1P TYPE FIRE PROCfSSED BY 0
.permit ts iswed,i skwll nW empby any persen in aup awnner '-�� � C T. ZONE - V
ao.os ro 6ewme w6jed�o the Wonrka`re'Compte�nsation\Laws. ���
Date FS-a9- (o (�Y�' �"1 '4 ��.� on ziP ��T 6',rj l v , O
�Appticom �n� sransncai anss��tcc N avr. c f.
NpTICE TO AVFLICAN[:�lf,.aker maki�this Certificate-of ARCH�7ER IXt TEt... ap � V
ExamptiOn,.you Should-�came w6j.ct ta..iha.1Nacke�i ENGINEER NO. !6 CLq$$Np, pWE1L.UNITS_ W
. Compe�smion provisions of the Labor Coda,-yo�must fwth- AppR€ss � S�wER,�ap y
witb tomply with a�ch provisions or this permit shall be T� Z
deemed revoked. coyfancrat No. gK. rc, VAUDATION
LICENSED G6NTRACTORS�GIARATILXJ uC.
� th�hyoffirm�drotlna,J;cenaee_,u��ox+s�o„zafs.t,optec9 ,�rs�ss� �Sarn � r,o.
I��^���9wilt�Secfion700D}afDivisiM�3�d#�e8t�ne�s�d - . . . . _ -...- - -- - � LIC. VALUAT[OqN � .
Rofesstons Code,and my{icense is in full fwce ond effect. diY - CLqSS S ) �� �
. - SO.FL NO.OF tJO.OF � CHECK . .. .
-. �license Numbar� .- .. .. . ..4ic.C�-.- - - Slff STORIES FAMILIES ONE
. . ... . .. .. . � ._. .._ .__._.._._ .._...__ . _. ...._. _._..__-_.__. _ . S_ ..
Cpntraclor ��g DESCRIPfION OF WORK �' �� z 1 4 1,0 A
�F am eaempi under Sec. � . . . y�' 1 ALtER � fINAL �?• • • • •�
� DATE 'zj ';�J�"::,
8.8P.C.for this reo�pn REPAIR ❑ 1 *�3 B 7 5
- . USE OF � �ti�y
oare onmr�s�ac. oF^tia ❑ � .1 . „ o��7 5�
..�.Signalurs-. . . _._-- -�---- ----.__� . APPtK�AR![_- .. . TEL.
OY�NER-Ell1LDER QFCLARAIIQI�1 . - PRlNT No. � . .- 0�.2 9-8 6
� �t hxeby affirm rhar I am exempt from�he Confracsor'a iicense . .
Law for ihe following reaaan(Sedion 7031.5,Businesa ond aooRE55
-Profession3 Code): . . . . . .. .. - . ._ .. . ... - - ..
� +, m�ownar ot��he � BUitoiNc _.
propeMy:a my�empFoyeea-with qpp�SS
wugas as their aole compensotion,will de the work and - � �
� tha structure ia not inrended or nffered for wte(Sedian �OC'°L�TY .
704l,8usiness�ond Professions Gode). � MOviwG -- 7et.
� I,as owaer ef ihe praperty,am exd�sively cantrecfing . TRAttOR . ' .. . . . NO. ._ . .. .
_ _ -
� with licensed-controctors ro mnstruct the projen(Seo- A�o2�u .
�tion 70M,Buaineas and Profeasions Code). _
��� � � -" -RE(NHRED � � TOTAi SEf&4CK FROM� EXIST.�
_ CONSTRIJCfION IEN�ING AGENCY - �7 gp,�K YARO� HWY p�p ��N WIDiH- ►
1 hereby affirm that them.is a construciion lending agency fw pgp� .
the performance of the work for which this permit is issued p.tr
ZSec.304T,Civ.C.�. Sw�
v.�
lender':Name . . . _�P �`
� . P.C.Fee= Vermif fee yO.`J
LBnder`s Add�ess
� I certify thai I hwe read this applimtion and state that ihe � � � Issunnce Fee �����
above informalfon is correct.I agree fo comp�y with nll County Invesnpauon Fae g 3
� ordinances ond$mte laws relatiny to building rn�shudion, Toro�FeE a;!��
tl and hereby au+hor�zo roprasenroNves of rhis Counry ro enter
� upon the obove-mentfoned pr��ctiort purpoaes. . . _ . .. . .
r1p� �}� p SEF REYEBSE FOQ EXHAIMTORY UHGUAGE
!� `�� Signaluro o�+1�'mM or Agent pc�e � " . .0s
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