HomeMy WebLinkAbout1038A WORKERS'COMPENSATION DECLARATION � � � �'- �
I here6y affirm thot I have a�e�,,���a�a oF�o�,e��,o=a�f - . APPLICATIO(V FOR �BUILDING �PERMIT
ins�re,o�o cerfificole of Workers'Compensafion Insuronce,
or a c/e��(�ified copy thereof(Sec:3800,La .C.) � �OUNT OF LOS ANGELES BUILDING AND SAFETY
Polic�No��a�^'Fompony__.. ���
� CerNfied copy is hereby furnished. FOR APPLICANT TO FILL IN BUIIDING �� �U O�Q�k �
ADDRESS
� Cerfified tepy is filed with the yQ ty building inspec- BUILD�NG f/�
. tiondeparlme /OJ`r�S d" �/� A�DRE55 � �l� Q
,��uate�PPlicant,r✓���/� Q��S atr nr l7 iocaurr
1 - CERTIFICATE OF EXEMPTION FROM WORKERS' � - NO.OF BLDGS. NEAREST / '/� /
- � COMPENSATION INSURANCE � SIZE Of l0T NOW ON lOT CROSS 5T.� I{�-�-K��/O GGL'
(This section need no�ba comple�ed if the permil is for ona .7�p . a55E550R
hundred doliors(E100)or less.) � TRACT BLOCK � sNLOT NO. M47 BOOK PAGE VARCEI
� ' OWNER Sw�"`Ep, $E 20NE N�+P / !3 �
I certify ihat in ihe performance of ihe work for which this ND• � }
permit is issued,I sholl nof employ any persan in any manner SPECIAL ��� �� S� Q
so as lo becoma subject lo the Workers'Compensatian laws. � ADDRE55 CONDITIONS 0
U
Da1e� Applimnt - � Cltt ZIP a .
NOTICE TO APPLICANT: If, after making 1hi5 Certificote of ARCHITEROR TE�. DISTRICT GROUP NPE fIRE PROCESSEDBY . O
ENGINEER NO. CpNST. ZONE F—
Exemption,�-you sho�ld becoma subjec� to.the Workers' / V
Compensafion provieions of the lcbor Code,you must forth• qooRe55 L'v W
with comply with such provisions or this permit shall be d
�• STATISTIG4�CU1551FICATION APT, CON�p. (n
deemed revoked. . � CONTRAttOR O. �2O'
LICENSED CONTRACTORS DECtARATION. p�, aASS NO.�[DWetL UNi75 Z .
I ere6y affirm Ihot I am litensed under provi71on5 of Choplet9 AODRE55 I•NO. ��R�P �
mmmencing with Section 7000)of Division 3 of the Bosiness ond � ���, /�
Professions Code,and my license is in iull force ond effed. CiTY �i{, � CW55 �7 BK � . . VALIDATION �
'M7l��xj///�7���� SQ.FT. NO. F NO.OF CHECK
litense Numb� �Llc.Clas�� 52E .2['l/ STORIES � - - FAMIUES ONE- .
C irocto��/y'e����fJate ` A D O s ALUATIO��s/�
DESGRIPTION OF WORK ��
I am exempf under Sec. 0 �"` ! � , �
TER
0.8P.C.for this reoson • / � EPAIR ❑ _ -
Dvte: �� /� r DFMOL ❑ � �1 0 3 8 A �
SignatVre � � �� � APPIICANT �. / FINAL �` 'rj �I� �•• . s e �
OWNER•BUILDER DECLARATION PRINT O. DATE �( d
I hereby affi�m�hot I am e�empl from the Controctor's license " " " I • �[����
Law for�ha following reoson(SeUion 7031.5, Business and ADDRE55 �FINAL . �
Prafessions CodeJ: � - - �� � PRE NT� 0Y • • •4 3.���
❑ BU�L�iNG
I, as owner of the properfy, or my employees wifh nDDZE55
woges os their sole compensotion,will do tha work and � � , ��C 2—fi B
tha sfrucfura is nol in�ended or ofiered for sole(Settion ����Tr �
70a4,Business and Profess�ons Code). MOv�NG � iEt. - � - .
� I,as owner of Iha proper�y,om exclusively contratting �aNTRAttOR NO.
� with licensed controdors to construct fhe pro�ect(Seo- - - qDDttE55 � �� - � � �
tion 7044,Business and Professions Code).
- �� CONSTRUCTION IENOING AGENCY � � SET BACK YARD HWY �OiAl�SEOTP`I�FR M ypIDTH - �
I hereby offirm Ihat thera is a canstruction lending agency for FRONT
�he performance of the wo�k for which Ihis permil is issued P.l. �
(See.3097,Civ.C.). SiDE
P.l.
lender's Name - �
.�z• /� IDAM Ref.N
Lende�s Address � � ' � � 7.0 Fee f Permi�Fee �� ,
1 te�tify Ihat I heva read this applitotion ond sleta that fha . Issuance fee. �� �`� `� LDMA P/C N
obave iniormation is conect.I ag�ea�o tomply wi�h all Counry invesrgm�on Fea
o�dinonces ond$ta�e laws�eloting lo building construtlton, Toial Fee r v � lDhu Perm.M
ond hereby authoriza representatives of this Counry to enter
�_po���ned pr erty r in etliOn purPoses• f . . ... .
O^ l�/
a ��A SEE RFVERSE FOR F%►LANATORY LANGUAGE
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