HomeMy WebLinkAbout1250A (6) �ERS'COMPENSATION DECLARATION �- � �� � ' � .,. ��"� � � -' -� -- " � • � - -�� - � � - • � � �
��!;�� �tha�I heve a certifica�e oF�o�=e�„o,e�F - -APPLICATION FQ� BUILDING PERMIT �
��sore, _..fico�e of Workers'Compensotion Insuronce,
b�o cernfied copy ihe.eai(Sec.3800,lab.C.) COUNTY OP LOS ANGELES � BUILDING AND SAFETY
Pol'cy No. Compony
� <e�titied copy is hereby tumished. FOR APPUCANT TO FILL IN BIIRDING ' IS /� •
- ADDRFSS (�
� Cerlified copy is liled wiih ihe couniy buitd�ng inspec- BUiI�iNG ) Mr p�r j� � . .. d�.
��D�deparlmeN. , . , . ADDRESS 17��///G/JJ/ir'
pete - APPticanl . � � � .. ' GTV u ZIP IOCALITY � •
CERTIFICATE OF EXEMPTION FROM WORKERS', _� . . NO.OF BtDGS. NEARESi /� ��
COMPENSATtON iN$URANCE SIZF OF lp� � � - --�NOW ON l07 � CRD55 ST. Vi.l�r C+ �
(This sed�on need no�be compleled if the permif is fo�one TRACY• eIOCK � lOt NO. Q AUE550R � .
hondred dollars(f1Q0)or less.) - �� 1, ey 1/ M/+D BOOK � PAGE PARCEt
S � AYQSI7I NO. aUU J US ONE MAP
I c0�tify Ihat in Ihe periormon o1�he wark for which ihis � ��ER ��/ Ap, C��'��j3 �' -
permit is issued,I Shpll�ol em y dny person in ony manner SPECIAI n'
so os�o become subjett to th rkeri Compensotion laws. ADDRE55 � � ~ �V dC) C0401t10N5 V
�Date�1���4PPlicant ' CITY N Z17. �7�7�p . . . . . . O
ARCHITECT DR �) TEt.
NOiICE TO APPLICANL�if, Ihis Ccrlifimfe of ENGWEER '��QG�ry� O. DISTRICi GROUP ryPE � FIRE PROCESSEDBY F-r�.
Exemp�ion, you zhoold be m o the Wo�kers' . . . y�� CONST. - ZONF i�
Compenso�ion provisiom of the lobar Code,you must ionh- qooze55 '�' 1 W
wilh tompiy with such provisions or Ihis permil sholl be �n J •�h N�
deemed revoked. � ' � —� TE�• -�� STATIS�ICAI C(ASS�FJ�.4TION �A➢T. ONDO. Z
CONTRACTOR - NO.
IICENSED CONTRACi0R5 DECIARATION� � ���, Qn55 NO._��pWEll,UNITS�
1 hereby affirm�hat I am licensed under provisians of Chop�er 9 ADDRE55 9 - NO. � � �
(commencing wirh Seclion 7D00)of Division 3 0(ihe Business ond ��� SEWER MAP ,
Profezslons Code;ond my license is in full torca and eHecL � �Itt '� � � � Ctn55 � �� VALIDATION
' $�.FT. NO.OF NO.OF CNECK BK. " PG. - - � �
Litense Number Lia Class � S12E - STORIES � FAMILiES ONE�
OESCRi7TION OF WORK vAIUATnION
N� Q ,
Contractor Oole ADD � s �v4�� ,
�I am ezempf under SeC. A�TER
0.8P.C.1or�his reoson �N� �t� w REPAIR � s ..
Qa��_ - USE OF � � DEMOI
Ex15TING BLDG. ❑
Signamre .� . nPvuCANi . . - . -. . . . TEi. ._.. . FINAL �/
OWNER•BUILDFR�FCLARATION PRIN7 NO. DATE� �
I hereby affirrrr tho�I am ezempl!rom the Comracbr's License � � � � - ��� � ��- - . �� � �_— � :'� G 5,�P
law for ihe following reason(Setl�on 7031.5,Bosinesa and ADD4ES5 F� . .
Pro/essions Code�: , ._ _ _.. . PRE ENT .... . . . A� �• • • • • �
(Q BWL�ING � � �
���� !, a:owne� of the property, or my employees wi�h qDDRESS � • �2 5 J Q
-� wages os their sole compensoiion,will do the work and � - . . . . . . . . - � .
the svuctwe iz nol inrended or of(e�ed for sale(Secfion lOC4liTV • • 0 2 J.G��
70l4,Business ond Pro/essions Code). . MOVING. TFI. . �
� I,vs owner of Ihe prope�ty,am ezclusively controtting CONTRAC70R � NO. � � D a 3 Q—8�5
. wifh licensed coniractors lo construcl 7ha projecl($eo- pDDRE55 � ��� ���� � - ' �� -- � - � �� �
��on 7044,Business ond Professiom Code�. � � .�
CONSTRUCTION LENOING AGENCY bE�BnCK YARD tiwY 10iAPROP.UNE WiDTH � � � '
I here6y affirm that there is a censtroction lending ogency for fROnt -
tha performante of the work For which this permil ie issued P.L. -
(Sec.3097,Civ.C.�. SIDE �
P.L, �
lender's Nome - � � � � � � �
IS�1 LDMA Ref.M �- � .
Lender's Address � � � - . P.0 Fee S Permii Fee _ ' .
1 certify ihm I have read this opplicolion ond slate Ihot Ihe Isauance Fee ��•, IDMn P/C N
abova informotion ii mrrecl.I agree lo tomply wilh all County � invesngo�ion Fee .�'., � . �� -
or o�ces ancJ State lows reloHng to boilding Construclion, taol Fee �r� IDALq perm.X � �
a hereby ouihorize repreeenmtives of this County to enter � � - � � �
u on�he abova-meNianed prope�ry for inspeUlon purpases. � � -
� � p�� .. . .. .. . . .. .. .. . _ . . . ..
_ ���5.'J✓h i\! SEF RFVE�SE FOR E%7IANA70�V IAMGVAGE
Signorura oF Applicanr or Agenl F�f—f7
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