HomeMy WebLinkAbout1645A Y�ORKERS'COMPENSATION�ECIARATION �� ��� � � � � - . _ �� '��� �� "" ���-� -' � " �-�, - �
I hereby aHi.m ��a�I hove a cer�iiiw�e of�a�=e�f�o=e,f - --- - -- � APP-LICATION � FOR�BUILDING PERMIT �
inwre,or a cerr�fica�e ot Workeri Com ensation Insurance,
or o cen�f�e copy thereo�,((S,yec.3800 b.C.) . COUNTY OP LOS ANGELES BUILDING AND SAFETY
PolicyNo. d�ponr 0 �'
� Ce��fied copy�s hereby lumis ed. FOR APPLICANT TO FILL IN suuowG /'� ,/�/� � �/� 1�
ADDRE$$ � O`� /�(G�+'�/
Cerlified copy is filed wilh ihe county building inspeo- BURDING 1
� . ��o�deporfinenL . ADDRE55 l-� d. ', 'A-rn t\,T
'
Da1C�Applimnl CITY �� MC/�U (�i-� ZIP �p�,q��Ty
I�/} TIFICATE OF EXEMPTI N FROM WORKERS' NO.OF BLDGS. NEAREST �.1 l� r.t�
'� •/�� COMPENSATION INSURANCE • SIZE OF LOT �� NOW ON LOT � GROS$ST. �J .J \O� v�
("Fhis seUion need nol be compieted if ihe permit is for one ASSESSOR
hundred dollars(5700J or less.� � - TRACt � BLOCK � LOT NO.- - -� M,qp gppl( - PAGE PARCEL
. . - I I TEL � USE ZONE M4V }.
I certify Ihol in the performonce of the work for which this - - OWNER , NO. C�� � f� � / a
permit is Issved,�shall nof employ ony penan in any manner qDDRE55 � !�/ S�' SPECIAL� _ O
so os to bemme subjec�to the Workers'Compensotion lows. _ 1 CONoinONS � U
- �� ' - ' CITY I�m���O !ST 21P . �
Data ApplicaM . O
NOTICE 70 APPLICANT: If, o(te�making this Certificate of ENG NEER �R T� DiSTRICT GROUP ttPE / FIRE PROCESSED 8Y �
Exemp�lon, you should become subject to the Wo�kers' _ . _ . , _ .. . - � � - CONb'r�� � �. W
Compensation provisions of ihe labor Code,you must forth- ADDRE55 �� a'
with camply with such pravisions or Ihis permit sholl be �
deemed revoked. � � ' ' '• � ' " ' � � ' TF���� / O Sinit5nG4t iFI�TION . AVT. CONOO. Z
CONTRACTOR - CC�i NO.
UCENSED CONTRACTORS DECIARATION � ��. ��� CLASS NO. DWELL UNITS �
I hereby oNirm thot I am litensed under provisioni of Chopfer 9 � A�DRE55 �.�U: � NO ,� ��R�P �
(mmmendng wifh Section 7000)oi Divislon 3 of the Business and r �, UC. n 2 �
Professionz Code,and my license is in full force and eHect. Cltt�1 /�- - QqSS l.-/ VAL��ATION
Sq.FT.� J NO.Of NO.OP CHECK ' - BK. �� PG. - �
licensa Number Q� lic.Closs�`i � SqE. . S10RIES' FAMILIFS � oNe - � � � •
] VALUATION� �
Conlrottor�_Ca,l ���j Dota . _ �ESGRiMION OF WORK e` � lI� N� ❑ s (O� , . .
J°t ecr� � e er � AD° �
�1 am exemp�onder Sec. AUER�-�
8.8P.C.for this reason �� U REPAIR ❑ s
Dale: � USE OF. . . .- . . a
E%ISTING BIDG. DEMOI ,
$ignCfUre - . _ APRIGN /. . -TEL Q qC FlNAL
OWNER-BUIIDER OECIARATION PR�N � � S� e �' / d DATE�(�-L�
I he�eby affirrtl that I am exempt from tha Canfratlor's License ADDRESS rt�U f� 6� A�n�
Law for the following reason�Section 7031.5,Business and FINAL . �
Prafessions Code): _ � _ . _.._. . PkE EM . . _ . . ... BY .
❑ BV4D�NG , �
I, as owner of tha property, o�my employees with nDDeE55
wo9es os their sole mmpensation,will do the work and - . _ . . - .
�he structure is not imended or offered for sale(Settion ����TY , .
7044,Business and Professions Code). MOVING � _ __, . TEL _ . _ .. � . �� 6�Jr A
� I,as owner of fhe p�ope!ty,am exclusively co�lrocting CONTRACTOR NO.
with litensed coMroctors fo conslruct the projact(Sec- - ADORESS - --� � � � �� � � � � �
fion 7044,Business and Pro(essions Code). •
CONSTRUCTION LENDING AGENCY . .. , SE 8A0C YARD. HWY 10iApROP IINE - Wi�TH -� ---- �- � � . � ��b a O O
I hereby affirm 1ha1 there is a consrruc�ion lending agency for FRONT � e 6 8�n=
ihe perfermanca of the work for whith this permit is issued p.t. . � �
(Sea 3097,Civ.C.). SiDE
r.t. D9.19-88
lender's Nome �- �-� - '-���� -' � �
� .� IDMA Ref.N .. . .
lender's Address _ . P.C.Fee f Permu Fee . . ' . .
I ce�tify that I have reod this opplimtion and slote that the �aauance Fee � V l➢MA v/C N � �
obove information is conect.1 agree ro comply with otl County ' - Imesrigarion Fee �,` - �
ordina es end Sta1a laws relating fo building tonstruction, To�ol Fee � v� LDMA Perm.M
on er by ovthorixe represematives o(Ihis County to enter --
n e abova-mentioned roperfy f speclion pu�poses.
„/J' .�� =J��� SFE REVEKE FOR EXPtANATORY UNGUAGE ,
ignomre of AppGmn�or Agem po�e , . .. /
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