HomeMy WebLinkAbout1431A 1469A WORKERS'COMPENSATION DECLARO,TION �
I heraby affirm Ihol I have a ter�ificota oF consen�to self APPLICATION FOR BUILDING PERMIT � �
insure,or a tertiiico�e of Workers'Compensotion Insurance,
or a certiFied copy the�eof(Sec.3e0o.lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑oliCyNo. Company BVIl01NG 1\��t-�
� Certified eopy is hareby fvmished. FOR APPUCANT TO FIL IN AD�RESS "y �
� CertiFied copy Is filed wirh rhe coonty bdilding inspec- BUUDiNG �7
tion deparlmenf. ADDRE55 �� Y�%�
.•Date Applicanl CITY � C✓ �.�✓ IP �I IOCAIITY `I
CERTIFICATE OF EXEMPiION FROM WORKERS' � � NO.OF BLDGS. NFAREST ,
-COMPENSATION INSURANCE Si2E OP LOT NOW ON LOT CRO55 5T.
(This seclion need not be compleled if Iha permit Is for one ASSESSOR
hondred dollors(E100)or less.) . TRACT BtOCK LOT NO. MAP BppC' PAGE PARCEL
� r i TE�• /�fJ USE ZONE M�P
I tenify thal in the performance of 1he�work f!r which this ��ER m No. p�p. �
permil is issued,1 sholl not employ ony person i�11 any manne ADDRESS O � V li� OENDITIONS �
so as to betome s�bject io the Workers'Compensotion L s. 0
� /� � GTY ' A� ZIP / � . . �.
Dote � Applicant ` � qRCHITEtt OR � TFt.
NOTICE TO APPLICANT: If, after aking 1hi7 Cerfifica e of ENGINEER N� DISTRICT GROUV TYPE FIRE PRO SSED BY O
Esemprion, yau should becom subject lo �he-Workers' �rt � CONS�`1 �� 20NE� � V
Compensation provisions of ihe l�abor Codo,you musf forth• ADDRE55 v v W
wlth comply with s�ch provisions or this permil shall be . . ��� iF�, STATISTICAL G1N551FIGATION AVT. CONoO. �
deemed revoked. � � � . COnIiRnCiOR ' 0 I� NO. • Z
LICENSED CONTRACTORS DECLARATION - � ���,� MSS NO. � �wEIL.UNITS �
i hereby affi�m that I om licansed under provisions of Chapter 9 ADDRE55 NO. ��R�P
(mmmencing with Section 7000)of Divislon 3 of the Busineu and , . _ _ _ _ p�, __
Professions Code,and my�imnse is in(ull force and effect. CITY M55 BK � VAIIDATION '
� - SQ.FL NO.Of NO.OF CHECK
Ucense Number � lic.Class� � SIZE STORIES - FAMILIES ONE �
VALUATION
DESCRIPiION OF WORK N� '❑
Contmcfor� � Date � � AOD ❑ f ` ,
❑I om ezempf under Sec. - AITER � , �� 4�� A
B.dP.C.for fhiS recfon REPAIR � s � #• • • •�2 3
Da1e: USE Of DEMOL ❑
EXISTING BIDG. I • •2�O O
.... Signalure . �- . . APPIICANT iEl. FINAL (�
OWNER•BUILDER DECLARATION � PRiM NO. DATE.'� 0 - - • • •G a O O c=i
I hereby aff(rm that I am exampt from ihe Contractor's License .
low for the(ollowing reason(Sectlon 7031.5,Bus�ne�s and A��RE55 flNAL'
09,07-88
Professlons Code�:� � -- - "- �y �
� BUIL�ING ` — _ �f;
I, os owner of the propeily, or my employees wilh AODFE55 !.;�1` t�
wages oe their sole compensotlon,wtll do ihe work and ���n, � ��I �����1.j , ,
the slrucfure i�not intended or oifered for sale(Sectian , � �J t
7044,Business and P�ofessions Code). MOVING � � � �TEL
� I,a7 owner of Ihe property,am e�clusively tontracting CONTRAttOR NO.
with Ilcensed contracrars to consfruct the projett(Sec- qDDRE55
tton 7044,Business and Profes�lons Coda).
- CONSTRUCTION LENDING AGENCY SEI�BACK' YARD NWY iOTnPROP LiNE wiDTN -
I hereby affirm that thera is a tonstruttion lending agency for FRONi �� 4 6'9 A
the perlormonte of ihe work ior which Ihis permil is issved �F.l.- � - �
(Sec.3097,Civ.C.). SiDE #• ' • • • �
F.l.
� lender's Name (��- �pMA Ref.N � ' •3 6 7 5
Lendei s Addrc:s • - � P.G Fee S Pe�m�r Fee d.-7 , •3 6 7 5 c=.�
• •
I tertify Ihal I have read this applim�ion and state that the . .. issuonce Fee LDMA P/C M .
obova informotlon Is mrrett.I agrea fo comply with all County Invesugarion Fee f� � ' �9 Q 8—$$
ordinances and S�ate laws relating�o building constrvction, ioial Fee �� 1 LDMA Pmm.N �
ond her by uthoriza representatives of this County to enter � . .
vpon t vb ve• e tio r6p fy for inspection purposes. , . �
�. _YL�� - SEE REVEIISE FOR EXPLANATORY IANGUAGE .
�gna�u e o Applicon�or pole
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