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1470A
WORKERS'COMPENSATION�DECLARATION � � � � � I hereby a(firm that I have a certificale of�e�,e�,�o,e�f - � � - - APPLICATION FOR -BUILDING PERMIT � � inaure,or a cer�ilitate of Woikers'Compenso�ion Ins�rance, or a ceriiiied copy rhereoi�Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Compony BUILDING ' � Ce.ii(ied copy ie hereby furnished_ . FOR APPLICANT TO FIL IN qppqE� �4�� v�,y,� � ❑ �Cerlified copy is filed with the county building inspee- BUiIDING n �l� ,/ � tion departmeM. . � . . � ADDRE55 U �"' •Dole Applimnf �. . � � CITY �v rJ���� ZiP I IOCAtITY `I Cl�h � CERTIFICATE OF ExEMPTtON FROM WORKERS' - NO.OF Bt�GS. . . n�aeESi � -COMPENSATION INSl1RANCE � SiZE OF lOi NOW ON tOT CROSS ST.� � Q�� (This section�need not ba comple�ed if the permil is for one . . . . . /�SSEUOR . hundred dollars(5100)or less.) TRACT BLOCK � LOt NO. Mqp BpOK PAGE PARCEL TE�' USE ZONE �+P I certify that��in the performonre af the work for which this �� � �`�'�ER NO. pp. ` permit is issaed,I sholl not employ ony�person in ony manner pooRESS � Y��� CONDITIONS n" so as�o become subject to the Worken' o pensaHon s. - O , • .. � � / CITY /Y� �✓�C✓ ZIP � 6 � V NOTI P 1 ANL• If af r makin �this Cerfifimte o ARGNITECi OR TEL OISTRICT GROUP NPE FIRE PROCESSED 6Y � Exemption, you ehould become su �ect Jo t e or ers - ENGINEER NO. CON�ST. --1 ZONE U Compensarion prov�sfons of the lobor Coda,yo�must forth- A000Eu �� v�' W wi�h COmp�y witfl SUCh pfovlStOns Of lhis permil Sh41I be .,s,d � h(, STATISTICAI QASSIFIC/1T N � APT. CONDO. (n deemed revaked. CONiRACTOR �'`� - NO. Z LICENSED CONTRACTORS DECLARATION �i�.� . MSS NO.�WEtt.UMTS � ' I hereby affirm that I om licensed under provisions of Chopler 9 ADDRE55 NO. ��R�P (commencing with Section 7000)of Division 3 of the Business and �i�, Prbfessions Coda,end my litensa fs In full torce and eHect. CiTY � CLA55 � - � ����� �-�-��� �� - � ���� VALIDATION �� � � � � SO.FT. NO.OF NO.OF CHFCK BK�-� -PG: license Number � Lie.Class� SIZE � Q STORIES � FAMIUES � ONE VALIIATION ' DESCRIPTION ORK N� � pO C❑ontraUor - �Date . ... �O . - - � s , . . �,� ADD I am eRempl under Sec. � ALTER 8.8P.C.for thiz reason � REPAIR ❑ f � - -� � - � - -Dale:- USE OF OEMOL E%ISTING IDG. ❑ Signature � �� APa� - FINAL OWNER•BUILDER UECLARATION N � DATE Ihereby affirm that I am exempt from the ControUvr's Licrose �- - ����' '� ' - " , � �ow for the following reoson(Sec�ian 7031.5,6usinees and ADDaE55 FINA � � Profeesiens Code): �- � - � �- � � - peE Ni � BY ,�y� BVILDING Q�j I,as owner of Ihe properfy, or my emp�oyees with AODRE55 �" wages as�heir sole compensation,will do the work end ���TY , z 1 4 Z 0 A the structure is not in�ended or offered for sale(Settion 7044,Business and Pro/essions Code�.- � - MOVING - � - � iEl. #• . • e e � \�' I,os owner of Ihe properfy,am exclusively contracting CONTRACTOR NO. wilh licensed contractors fo conslrucl the project(Sec- qDDRESS � • •4 9.2 5 � tion 7044,Business and Professions Code). - -� � - CONS7RUCTION LENDING AGENCY � - �� - sE�encK� �ARo Hwr T�rAPROP.LI�NE� wi�rA � � - ' • °4 9,2 S� 1 hereby o(firm thm the.e is a constroction lending ogency for fRONT the performance of ihe work for which this permit is issued . P.l. . . . . . ,. . . �9�$—8 8 ($ec.3097,Civ.C.). SIDE P.L. . _. . . . _ . . _ . . . Lender's Name IDMA Ref.M lender'S AddrelS � � "� � � � P.C.Fee S - PermR Fae- - - ' I tertily thal I have road this oppllcalion and stata that tha . Iswance Fee S LDhV+v/C k _ obove informolion is correcf.I agree to comply with oll County Invesrigoiion Fee o�d(nances and Slafa laws reloling fo 6uilding consfr�cfion, ioml Fee / IDMA Perm.M 'and hereby a �horize reprcsenmrives of this Coumy to anter - � upon tha -men�i ned property f inspection purposef. ���, � SEE REVERSE FOR EX�LANATORY IANGUAGf o�A I�on�er A eni poie �� - - � � - � � � _ . . Z ...� � � ry ,� � __ { __ ,-- '` p o a o n� n a a o � a m ! �= ^' " `n ° m° � 0 7 ^ ' ^ o ��c .-p s .n , --, �'� o 0 0 ° n o _c_. � . 'v,o � c �� -c- `0 �:: o rv " D!, ; + � �o � 7 ? �n m o ° o � � � �7 !1� �� _�.`\ ' � Y .o ; i \: '� 7 0 �� r` � fn c7 O ` � � � 9 �= O V 1 ? � _ � f3'+ p •,p '� '�•. 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