HomeMy WebLinkAbout4521 4540AWORKERS' COMPENSATIONDECLARATION-
hereby a I have certificate of consent to self -
m_"PILI1111 ATIJOcertificaterinsure, or o certificate of Workers' Compensation Insurance, 1-FOR t BIVILD. ING- PERMIToracerlifiedcopythereof (Sec 31104, Lob. C.)-" 4r -
COUNTY OF LOS ANGELES BUILDING AND SAFETYakPolicyNowRsPaelsjor, iny U, .r,,at:a FL,,,A
a . Certified copy is, hereby flrrnished.- _ FOR APPLICANT TO FILL IN BUILDING t
PY ( _ county 9 sP-- 0- -Certified co is fi ed with the coup building Inspec- tton'deparimeht. - BUILDINGADDRESS
ADD— ADDRESS
12-1b-FLS
Dore' j AppFicant?\.e..7 _s` C Qn V P CITY ZIP LOCALITY -
CERTIFICATE OF EXEMPTION FROM WORKERS` '_ ... .-s. s___-.._. gF..gLpGS_----_ NEAREST_ A
COMPENSATION INSURANCE - - - SIZE OF LOT NOW ON LOT CROSS ST. t1K CL
This section -need not. be coritpiefed if. the permit is for one
TRACT j BtOC[ . rJO. - BOOKiwndred. dollars ($100) or, less.) - C i PAGE. PARCEL
I certify that in the performance of the work for which this
TELAfdll
owNER NO- USE ZONE -..
n_1 MAP.. NO. 1 ' ^' y
permit is issued, I shall not employ any person in any miner 074 - so as to become subject to the Workers'.Compensation1aws. ADDRESS/ q'
PECIAL
CTJ D CONDITIONS -
ry
Date ' `'- Applicant - _
NOTICE TO APPLICANT: If; -after making this Certificate of
QTY-___.iJ -_ _ ____ _ZIP .. .. .. m
ARG Lp77 DISTRtC( GROUP TYPE FIRE PROCESSED BY
Exemption, you -should became subject to the Workers '- -
Compensation of the Labor Code, must forth-
NI
ERry CO / Z
provisions you
with. comply with such, provisions Es ihispermit sha11 be .._.
ADDRESS
W
TEL
V v a' N
deemed revoked., ,.- .:.` - CO-; CONTRACT SO NO.
STATISTICAL CLASSIFICATION APT. C Z
LICENSED CONTRACTORS DECLARATION _ tic. CLASSNo tiS_E,7=DWELL. UNITS
I hereby affirm that t am licensed under provisions of Chapter 4 ADDRESS NO
commencing with Section 7000) of Division 3 of the Business and - - UC. -__
SEWER MAP
Professions Code, and my license is in full force atm; effect. CITY CLASS VALLDATIWJ
License Number i \ S 19, C" Lia r'la«
so. f7.. _.____ NO OF NO. OF -
FAMILIESSIZE ' IS CHECK . ONE
DESCRIPTIONDESCRIPIKP0F WORK NEW
VALUATION
ConiradorT
ADD _ t
I am exempt under Sec:
Al7ER
B.&P. C. for this reason - PAIR _-Q s - 1 • • 2 E C o
Date: - USE OFEXISTING BLDG. XMOL 2 S Q O h-
Signature - ifpRjNT%%1+ M.
7 FINAL. 12,12-85OWNER -BUILDER DECLARATION
hereby affirmthati arn-exempt.frarn tk.Conk lorx .License -.- - t.-I
DATE -.-
Low for the following reason (Section 7031.5, Business and ADDREss h FINAL
Professions Code): z ._._ „._ ..._ `-- -- ---__ e.: -------
1, 1, as owner of the property, or my employees with BUILDINGADDRESS -
f o rhe work andwoges
ct
their sole
intendedofferedthestructureisnotintendedoroffered for sale (Section LOCALITY 1) z of 5 LL A
7044,-Business and-Professions-Codey. - ----- - ------ MOVING`-"- - -- -- --- ----- TEt. r(;y -- - a 1
1, as owner of the property, am exclusively contracting
with ilcensed
CONTRACTOR NO.
I 0-3675contractors
tion 7044, Business and Professions Code). ADDRESS F
P ,; 3 % i65
CONSTRUCTION LENDING AGENCY - REQUIRED_ - TOTAL SETBACKREQUIRED_ BACK: - YARtr- --MWY^ "-' .PROP. LINE WIDTH' y _-_-- - _ - -- -
F herebyaffirm that there is a construction lending enc forg v FRONT 1216-85.
the performonce of the work for which this permit is -issued - - PA.
Sec. 3097, Civ. C.). SIDE-
Lenders Name tie: 11iy k t1; moi s
LDMA Rel it
Saltr's AddresssZs l • La \ Cc i C.bpr%L LendeS .
P.C.Fee,
1C.
4,
F. certify that I have readthis application .and state. that the (rp( Issuance Fee O - LDMA PAC It
above information is correct. I agree to comply with all County tnvesiigarion Fee -
g ordinances_ and State laws relating to building consirog on, TORaFfee-9-c"_-- - LDMA Perm. NuandherebyoutrepresentativesofthisCountytoenter-
ppon the above-mentioned propert for inspection purposes.
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