HomeMy WebLinkAbout1748A WORKERS'COMPENSATION DECIARATION �
1 hereby affirm�hat I hove a cenificata of consent to self APPLICATION FOR BUILDING PERMIT
insura,w a cerlificata of Workers'Compensation Insuranca,
or o cartifiad topy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAF
Policy No. Lompany
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDR ss Q t�0
`� Certif'ted copy is filed with flfe county building inspec- BUILDING n S/ L/ �
f--" tion departmeM. '�} ADDRESS �(C9 �� �!/ � ��/ IOCALITY .c
G�J^�A � � '�• CITY /�D/�/�.- /.r ZIP CROS55T.
Dote Applicant _
CERTIfICATE OF EXEMPTION FROM RKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE Slze oF�AT NOw ON LOT row.e BooK rnc,� raRCEL
(This settion need nol 6e completed if the permit is for one TRACf �? d �- USE ZOnIE MAP �
hundred dollars(SI00�or less.) � BLOfK l0T NO. �— NO. � ==�3.�
TEL. �CIAL
I certify that in the performante of the wark fa which this OWNER � � C� NO. CONDITIONS �
permit iz issued,I shall not employ any persan in any manner �+ �+ p DISTRICT GROUP TYPE FIRE BY o
so ac to bewme subject to tha Workers'Compensatian laws. A��E� / G�/O/C./�%G � Z� � 3 CONST. 2� U
CITV
.Glfil�� �f-J C ZIP � � 0
Dafe Applicant STATISTICAlUAS51FICATIDN APf. CON00. h
�'7TICE TO APPLICANT: If, aher making this Cerlificale of ENGINIEER � �''� TNO. U
�nption, you ahould become su6ject to the Workers' ClAss No. DwEu.UNI75_ �
�. mpensation provisions of the Labor Code,you mus�fonh- qDDRE55 � SEWER MAP z
with comply wifb such pro�isions or this parmit aholl be �
deemedrevoked. COMtRACTOR- :✓/Ll IT Sy TNp. ` '� •}` BK. PG, VALIDATION
IICENSED CONTRACTORS DECLARATION !/
1 hereby affircn MW I em licanud under provisions of Chapter 9 MDRE � n � A� 1 NO.������l VALUATION ��
(tommencirg with Section 7000)of Division 3 of the Business and n / ���, j
Professions Code,and my license is in full force and effect. CI7Y �/` �4`!' CIA55 �"2� E ��G
S9.Ff. NO.OF- NO.OF CHECK
Licensa Numbe� lic.Clasa SRE STORtES FAMIl1ES ONE �� , 4 f;h,
Co�hoclor pote 'J�L�j
DESCRIPTION OF WORK f�/I�'f/� �L L L NEW �{ s �r' � � �.�:+'
�I am exempt under Sec. '�O `- � �' A� — � � � !- ``• `
� T ntTER � PINAL � • o s i�.`�'.'�
B.BP.C.fw fhis reason °��1\ f' ! REPAIR � DATE l���d' . ..`�
Dafe: u5E OF FINAI U^�'�:-'—;,•
FXISTING BLDG. ���� D
$iyncture APRICNJT d� �1� �TEI. � � _�C� � '
OWNER-BUILDER DECIARATION PRINT � G/I' / M10.C � ,I�6 � � � ���
I hereby affirm thm�om exempl from tha Contrxtor's Licanae / ? �• _
Law for the following reason(Set�ion 7031.5,Business and A��E /6 � `���"y f ����~�� - � � � ���� t t;
Professiona Code): PR � ,. �.`r�?
i
� - ----- -... __._.... _. _ •�.._ . .. :
BUaWNG
�' I, as owner of rhe propeny, or my employees with noocEss --
� woges as ihair aole compensatlon,wil I do the work and L�L TM �j.: ,`=._i.�
the shucture ia not intended or offered for wla(Section . - .
7W0,Business and Professions Code). MO�iNG 7Et. � , , G�
� I,as owner of the propeny,am ezclusively contracting NTRACTOR NO. /
with licensed contractors ro conshucT the projecr(Sec- qo�REu , - �%�,S � •
tion 7044,Businesa and Profassions Code). ,
RE�UIRED TOTAt SEfBACK FROM EXIST.
CONSTRUCTION IENDING AGENCY SEf BACK YAR� HWY pppp.�IN WIDTH �
1 hereby affirm thar ihere is a consir�cTion lending agency for pRpM �
the performonca of the work for which�his permit is issued P.�. /��--'
�Sec.3047,Civ.C.). SIDe _ l �
m v.i. j� [
� Lender i Nome / 6 �J
$ Lander's Addrau P.C.Fee E � Permit Fee ��- �
� I certify that I have read this applitation and slale that the iuuon<aFee���
a obove information ia coned.I agree to comply with oil County Investigation Fee /
� ordinances and State laws relating ro building conatr�ction, Torol Fee W ��
nnd hereby au�horize representatives of this County to antar
� upon ihe above-mentioned properry for inspection purposes. -- � � �--� � �
^ �' �, �`�.f=�-
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