HomeMy WebLinkAbout1347A (7) WORKERS'COMPENSATION DECLARATION � �
I hereby affirm thot I hava a-certificale of consent to salf APPLICATION=FOR.�BUILDING PERMIT �
insure,or a certificate of Workers'Compensation Insurante, �
or a certified copy thereof(Sec.3800,lob.C.) _ . . COUNTY OF LOS ANGELES � . �BUILDING AND SAFETY
Policy No. Campany � ' " � � � - � - '
Certified copy is hereby f�rnished. BV�lDinlG Z,f 3 T ti. _ .r11 �� �
❑ FOR APPLICANT TO FILL IN no�aess r � vi,o-v�c„
� Certified copy is filed with�he caunry buiiding inspec• BuaDiNG �t1 L �
lion department. ADDRE55 333 AC LOUIITY. - W �+�o-1�� f�Lw .
♦ �1 �G NEAREST
Data Applicant Cltt�i\A 8�/D A� ZIP (k CROSSST.
� CERTIFICATE OF EXEMMION FROM WORKERS O-D�9L6G5. ASSESSOR . �
COMPENSATION INSl1RANCE SIZE OF lOT IT O S NOw oN l0T MAP BOOK vAGE VARCEL
. (This section need nat ba compleled if Ihe permil is for one µ u5E ZOME MaP
hundred dollars(EI00)or less.) - TRAR � BtOGK LOT NO.'yf �_1 NO. �2..d`��
� ��TEL: � � � SPECIAI
I ce.tify that in the performance of th'e work for whith this OWNER J ' p No. C�D CONDITIONS � � �or.
permit is Issued,I shall not employ any person In any monner � --- .- ._.. _ DiSTRiCT GROUP TYPE �' FIRE PROCESSED BY �
- so as to becoma sobjecf fo the Workers'Com satlon Laws.. ADDRESS � as -a.be��e . �U � CONSTr� ZONE �� �
. _ . . ... . . . ...'___._..
w"`�V
� /�
Dafe ApPIICOn} • ' ��TM f�/ Z�P STATISTICAI QASSIFICATION APT. CONDO. �F
NOTICE T •APPUCANT: If, after making Ihfs Ce ficote�of NGNEFR�R �/ - NO. - � - � -� V
�Exemption, you should become subject lo the orkers' CW55 NO.��WELL.UNITS a
Compensation provisions of the Lobar Code,yov musl forfh- ADDRE55 SEWER AMP y
wiih comp�y wi�h such provisions or this pe�mit shall 6e � � � Z
deemedrevoked. ' TE�• . gK,._ .p� VALIDATION � �
CONTRACfOR >LS� ryp,
LICENSED CONTRACTORS DECLARATION i�C. . �
I hereby affirm thaf I am licensed under p�ovisions of Chop�er 9 ADDRESS NO. VALUATION
(tommencing with Seciion 7000)of Division 3 of the Bvsiness and ��� � - � �
Professione Code,and my license is in full forca and effect. CiiV CLa55 S ��(�� , •
� � 5�.F7 NO.OF NO.OF �/, CHECK
License Number l(c.Class SIZE STORIES FAMILIES�/ ONE .
DESCRIPTION OF WORK N� f � - �1 3 4,7 A
CoMracto� Date � I��� ����� . ADD � - k• • � f • �
❑I am ezempt under Sac. q�TER � FINAL {�
B.BP.C.for rhis reason � � -- REaAiR�� DATE � Q� - I •�3�7 5
Da1e: USE OF DEMOL ❑ FINA •e .J Q'�5�
EXISTING BLDG. BY
Signotore APPLpRjNTi NO. �^ - �S.2 7"$b
OWNER•BUILDER DECIARATION _ �
I hereby affirm thof I om exempl from 1he Controcfors Licensa
Law for the following reason(Section 7031.5,Business and noortess . C Ct. �� • � - � � �
' ROfessions Code): " � PRE N - �� � -
�� I,as owner of�ha property, or my employees with AD�RE55
7� woqesastheireolecompensa�ion,willdotheworkand �
� the strod�re is nof infended or offered for sale(Sectlon ����T�" , . _. . _
7044,Bvsiness and Professions Code). MOVING TEL.
,� I,os owner Of 1h0 property,am exdusively conlracfing C NTRACfOR NO. .
wf�h Ilcensed contractors to construct the projecf(Sec- qooRE55
tion 7044,Business ond Professions Code�. .
REOUIRED TOTAL SETBAIX FROM E%IST. �
CONSTRUCTION LENDING AGENCY SET BAGK YaRo HNn PROP.LINE �✓��TH ,
I hereby affirm that Ihere is o mnstivtlion lending ogency for fRON7 . .
the performance of the work for which this pe�mit is issued P.L.
�SeC.3097,Civ.C.). � SIDE
. . . P.l. . . .. . . . _ _
lender's Name
i
lender's Address P.C.Fee f Perm�r Fee
I certify Ihat I have read�hls application�ond srme rhot tha � i:suonce c�, I V. �
a6ova information is conect.I agree lo comply with all Counfy Investigation Fee � �
ordinonce3 ond 51o1e laws relating lo building construction, � Toiol Fee (� • '
and hareby authoNza represenfclives of this Coonty to emer .
upon tha abova-myntioned property for inspaction purposes./� � � � � _ . . - . .
` / � SEE REYERSE FOR EXPLANATORY IANGUACE
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