HomeMy WebLinkAbout1442A (8) WORKERS'COMPENSATION DECtARATION - '��� � � , �
�ps��eeo°�`�e,�f�o;eofwake�"�om'Pe�sa«o��n,��a��" APPLICATION FOR BUILDING PERMIT
or a certif�ed copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES.._ BUILUING AND SAFETY �t
PolicyNo. � Company � � ' � � 9 -/
� Certified copy is hereby furnished. � FOR APPLICANT TO FILL IN ADDRESS 0.�I/ JrtS A ,1`A/Y
� Certified copy is filed with the cooMy bvilding inspec- , euaDiNG �� ��}�
� tion deparfineM. � . - ADDRESS /� �j.. LOfAUN
Dafe � - Applicant Cltt zia 9��� caosssr. PF/Y J�
CERTIfICATE OF EXEMPTION FROM WORKERS' ' NO.OF BlDGS. n55E5SOR � '
COMPENSATION INSURANCE , SIZE OF LOT �Qd NOW ON l07 MAP BOOK PAGE PARCEL �
(This setfion need nof be campleted if the permit is for one USE��OO N /�nnr /�/��
hundred dollars(5100)o�less.) . � TRnCT BIOCK tOT NO. U� � - NO.
- TEL. � - �� M.v SPECIAI . }
I certify ihot in the performance of the work for which this OWNFR -�, b O. $�L�� N�' CONDITIONS n.
permit is issoed,I shall not employ any penon in ony manner DiSiR�7 GJ�UP TrPE FlRE PROCESSED BY �
ADDRE55 } /f CONST. ZONE V
so as to become subject to the Workers'Compensalion lows. . � �r 2 .! � � --
� I/
Oafe � � Applicant .. '. CIN .tl Z�P y STATISTiCAL QA I TION APt CONDO. �
NOTICE TO APPLICANT: If, after making ihis Certificote of AkCH�TEQ OR TEt.
�Exempfion, yov should�becoma subjetl fo the Workers' ENGinIEER �NO ��q5s Pp, pWELL UNITS a
Compensalion provisions of the Labor Code,yoo most forlh- . ADORESS - �v � - SEWER MAP . Z
with comply with such provtsions or �his permit shdll be -
deemed revoked. � � �� � �pp�7RACfOR NO. ���BK. �PG �� VALIDATtON
� UCENSED CONTRACTORS DECIARATION � ��C. -
I hereby affirm ihat I am licensed�nder provisions of Chapter 9 ADDRESS NO. ypLUATIpp N -
(mmmencing with Secfion 7000)of Division 3 of the Business and ��� /�OQ�m -�
Profeuions Code,ond my licensa is in full force and eHect Citt Ctp,SS E .
� � � � - .� ' SQ.FT. v NO.OF NO.OF CMEIX � _ . . �
License Number � � Llc.Class - - SIZE STORIES FAMILtES ONE
CoMracior pote . DESCRIPTION OF WORK N� ❑ f - .
I�T Q ADD. - . .. _ .
�I am exempt under Sec. ALTER � FINAL G . �
REPAIR � DATE ��.��v ,
B.SP.C.for this reason � � /. � �
Data: USE OF p�a FINAL j � � ,
� ExISTiniG BLDG. ❑ By /�/' �/
-- $ignafUfa� -� - ' . . - - APPLICANT 7FL ;
� OWNER•BUILDER DECLARATION �RINT No. �,, - � -�j 4�,2 A �
I hereby affirm that 1 om ezempt from iha Conlractor's Licensa
Law for tha following�reason(Section 7031.5,Business and . ADDRE55 ►- � -� •�� � � � t. . •-. • �
Professtons Code): � pRE ENi ' �
� � BUIIDING . , •'�v�`�5 _
1, as ownei of the property, or my employees with ADDRESS
wages vs their sole compensation,will do Ihe work and � � - � . � � � .� _
tha srruclure is not imended or offered for sala(Section ����tt _ •;�b r 5;�
. .
7044,B�stness and Professions Code). � . MOViNG 7E1.
� I,os owner of Ihe property,am exclusively mntratting .. NTRACiOR nro. ��2�1—�i�J
wlth licensed conhaUors ro constrotl Ihe projeet(Sec- a��REu � -
Yion 7044,B�sfnesz and Professions Coda). . _ . _ . .
� � -RE�UIREO TOTAL SETBAIX FROM E%IST. �
CONSTRUCTION LENDING AGENCY seT eneK YARD HWV Pf20P.LINE wiorH ► -
_ 1 hereby affirm thot there is a tonelrucHon lending agency for FROM � �_�� ��- � �
the performonce of tha work for which this permit is�ssued P.t. � .
t5ec.3097,Civ.C.). � � SIDE�
. � P.L.� . .. . .. � . : ... __. .... __ . . . . .
lender's Name � � h/ �
Lender's Address � - � P.G.Fee E� Permir Fee �.G�(�a'r � �
f certify 1ha1 I have read tbfs oppllmtion and stata that the � � Issuanro Fee /�sy
obave information is correcf.I ogree to comply with all Caonty Invmtigation Fee � 75 - �
- ordinances and State�aws relating to butlding mnstruction, � �� Toml Fee � -� �
ond hereby outhorize reeentatives of I ' County fo eMer � � �
upon the above-m �o ed property f m actlon purposes. -- � - ---�- -� - � � � - - - - ---�� � - � � - �
xl C� :� SEE REVERSE FOR EXPtANATORY LAHGUACE
. . . .. .. ..._. _.. _ . _ . .
Signamre of Applicont or Agem . poie . . �. .. . . . . .�t
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