HomeMy WebLinkAbout0902A (4) . �WORKERS'COMPENSAiIpN DECtARATION _. . . . � • � � - � �
Insoreborac�ertificatalofWarkerseCompenstf�°;��;a�°e3o'; � �-�� - � APPLICATION� F4R BUILDING��PERMIT -
a tertified copy thereof(Sec.3800,1a6.C.) COUNTY OF LOS ANGELES � �� BUILDING AND SAFETY
Policy No.� Company � � � � �
� Certified co � � � i - - - . BURDMG -
py is hereby fumished. FOR APPLICANT TO FILL IN nooRess'�. �
'i
� �Certified copy is filed wHh the coun�y building inspec- ' BVItDING [� ,Q � � .
lion deparlmenl. � �� � ADDRE55 J�(J� � � LOCALIN �
��.�. , . . . � . .. . � . NEAREST
Dole �AppllcaM� � � � - CITY�� � ZiP - CR0555T. C - �
- CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BtDGS. A55ESSOR - �
- � - COMPENSATION INSURANCE � SIZE OF LOT .. - � NOW ON LOL MAP BOOK PAGE PARCEL
(This:ectlon need not 6e completed if ihe permit is for one u5E zONE MnP �/
' hundred doilars(S10p)or less.) � � . . TenCi � �O BLOCK l0T NO.- �' � NO. ��3'..�Y'-r � �,
TEL:�� �Y7ry SPECIAL . , . y
I tertify Ihat in ihe performance of fhe work for whlch�his OWNER (t �� CONDITIONS � ' ' Q
.permif is iisued,I shall not employ ony pBrson in ony manner DISTRICT, GROUP 7YPE FIRE PROCESSED BY�
ADDRE55 CON57. ZONE
so as to become subject to the�Worker'Co sation Laws. � �� - �� � � O
Dafe ' � - Applican - vqv\ ��TV ZIP � � 51ATISIICAL CLASSIFICATION - �APT. CON�O. � W
V ARCHITECT OR - -�- �� . �TEt..
NOTICE TO APPLICANT: If, ofter moking Ihis Certificale of ENGtNEER NO. IXASS NO. ��DWELL.UNITS_ a
�Exemption, you should bemrtie subject to ihe Workers' ' �
Compenso�ion provisions af the Labor Code,you must forlh• � ADDRESS� -� - � � - � � SEWER MP.P � z
wilh comply with such provisians or Ihis permit shall be � tg, - -VAIIDAT�ON�,
deemed revoked. . - . � - CONTRACTOR� - - ' '- �NO. -� BK� �'•
' � - .�LI�ENSED CONTRACTORS DECIARATION � ���. _ . : � . - -
I hereby affirm thot I om licensed under provisions o(Chopter 9 :�::. nDDRESS �. � - �. �- - � .- NO.-� VALUATION � - , �-
(rommencing with Section 7000)of Oivision 3 of the Bosiness and. - ��� ' �, ,
Professions Code,and my license is in full force and ef/ect. CITY . CLA55 ' S �
� . ' - SQ.FT. NO.OF NO.OF CHECK ' . -
' License Num6er � � � � Lic Class - � - 9ZE STORiES � FaMiueS ONE - . � -� � �
� - OESCRIPTION OF WORK NEW ❑ E � �
Confmctor " - Date ❑ � � � - - ' � '
� I am exempt from the licensing requiremenh as I am a e� ,V�� � � -- A�o� . _
. licensed archilecl or p registered professionol engineer__ . . ._ . . . . AUER .❑ � FINAL �
. ocfing in my professional capacity (Sec�ian 705I, - � ' REPnIR � � DA7E j� ��/ � � 9 � -
Business dnd ProfeSsions Code). , USE OF , ❑ � Q 2'A
� EXISTING BLDG. � � - DEMOL � FINAL� ,
Bv #. . ..,1 3
Lic.or Reg.No. ' Dole APPLICANT iEL � � ,
�- � �- OWNER-BUIlOERDECLARATION ' - f�RWT�- — --� � - � tu0. � ��- • •
1 hereby offirm that I am exempt irom the Contrador's License ��� a ., . . . . ���..�'��g".`5 Q
"law for.the followfng reason(Section 7031.5,9usiness and ADDRESS �' � �� � � �/jC�T � •�• � _ -
Professions Code): � � veESetii , � � �.5 Q�'
D . . BUIIDING . . . _. ... . . . . . . � .
I,�as owner of the property, or my employees wifh ADDRE55 I 2 0 3-8`�
wages os their sole compensotion,will do�he work and _ : � : ;
LOCAL�TV . . --- . . - . .--..
�-� -the sirocture is not intended or affered for sole(Section "� -�-"--" - . � �
7044,Business ond.Profeesions Code]. MOVING . � 7EL � � � �
�� .I;os owner of fhe property,am exdusively coMrocfing � CONTRACTOR n10. - � - �� . .
with licensed coniractors to canstruct the project(Seo- A�DaE55 � � -
- lion 7044,Business ond Profess7ons Code). �-• �� ��� - ��- � - - � � � - - �
REOUIRED 70TAL SETBAIX FROM EXIST. - � �
CONSTRUCTION LENDING AGENCY SET BnIX YARD HWY PROa.lwE WIDiH -
1 hCreby affirm fhot there is a canstrottion lending ogenry for � ' FaOM � - � � ��
the performance of ihe work for which fhis permit is issued v.i. � �
.�Sec.3097.Civ.C.1. . - . . . . Si�e . . _ . . ........ .. .i � . . ... . . . ..
P.L _
lender's Name � '
Lender's Address � + P.C.Fee S Permii Fee /�'� O .. . � • . . �
I cenify�that I have read this opplica�ion and state thot the . issuonre Fee � v� �
above�nlormation is correcl.I agree to tomply wilh a�l Cooniy . . Inves��ga��on Fea � - � � �� � - �J - � � - � � �
ordinances ond State laws relating to bullding conshuc�ion, 7oiol Fee �l d•...�1� ' -
ond hereby ao�horize represenlolives of this County to enter _ _. , � . .�
- upony .abpve•me fio d�prope 1 fo/i ction purposes. . , .
(� ` ��P�.�,1 - SEE REVERSE FOR E%PLANATORY IANGUACE
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