HomeMy WebLinkAbout1195A (5) � WORYERS'COMPENSATION�ECIARATION � - �
I her�by offirm fhat I have a ceriifica�e of�a�se�„o 5e�f � �� � �- � APPLICATION� FO���BUILDING� PERMIT � �
insure,or o ccrtilicare oi Wo�kers'Compensafion Insurance,
or o certified coRy ihereof Sec.3800,ta C.� � - � �� � � �' �
G307z6—�� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Fo❑licy No. ompony ' �
Cer�ified copy is hereby(urnished. FOR APPLICAN TO FILL IN ADDRE55 ���Q� C �+�-�v�
� Cerliiied copy is filed with the county 6uilding i p eUitOiNG �- ? �, �
tion departmenL . � ADDRESS �J -
XOa�e '�I� Applicon C�Tv ZIP IOCAIITY
CERTIFICATE OF EXEMPiION FROM WORKERS' ._ NO,OF 6LDG5. . NFAREST _
. COMPENSATION INSURANCE � SIZE OF LOT NOW ON LOT CRO55 5T.
(This section need not be tomple�ed if the permi�is for one . �7 �]� nS5E550R . .
hundred dollars(E100)or less.) TRACT -C�/ BLOCK LOT NO." µ4P BOOK PAGE PARCEL
TEL. �J
pWNER -.NO. . USE NE �P ,�—3 TJ �•
I certify ihai in�he performonce of the work 1or which this � - ! � f 0-�
permil is issued,I shail nol employ any persan in ony monner qDORES � {� Uy-� SVE�iA� , (�j
so as io become subjett.to rhe Workers'Compensofion Laws. - / CON�ITIONS
. . . CITY /7rt/7 ZIP /�✓�^ ' . . . . �
Do�e aPP���a�� � ARCHiTECT OR iEl. O
NOTICE TO APPLICANT:.It, after making Ihis Certificote of ENGINEER ' � NO. DISTRICT GROUP TYPE FlRE PROCESSED BY �
Exemption, you should become wbjetl �o the Workers' . / CO�T' ZO�E W
Compensotion provisions of tha Lobor Code,you must(orth- ADDRESS G� N
wilh comply wilh�sv[h provisians or 1hi5 permil 5holl b@ TEL.- STATISTICAL CIASSiFICATION APT. K00. Z
deemed revoked. � � CON�RACTOR . ' • 7 / —
UCENSEDCONTRACTORSDECIARATION � LK.G 3�Jy,5'S7 �SSNO.�DWELLUNRS
I hereby oNirm that I am licensed under provisions of Chap�er 9 ADDRESS 3 NO.
(tommencing with Section 7000)of Divislon 3 of�he 8usiness ond /�� p�, ��R�'P
' Professions Code,ond my license is in full force ond effect. � UTY(/ •O - � � C1n55� � � - BK � � YALIDATION
vSs7 7 3 � �'FT. NO.OF NO.OF CHECK
Licensa Number Lit Closs��� � � S12E - -- STORiES - FAMILIES - � ONE _
VALUATION `
Conlrottor �G DESCRIPTION OF WORK A ❑ f � V" `� ;� � 9,.�,fl -
�I om exempt under Sec. ' /V.-. � // TER ,
Q s �e • • e • �
B.BP.C.forthis reason � � � � REPniR � � � - � �
Date: EXISTING BLDG. DEMOL ❑ I • •7�,G J .
Signature A7PIICANT - � TEL. ' PINAL �y*y� ![7.'�5 T
OWNER-BUIIDER DECLARATION PRINT� Na� DATE •�`�p/ � � � �
I here6y aifirrrt ihat i om e.empt irom�he Comracroi s license - - - � � - � - ��� � ' � �'�- �$2 6—8 8
Law for the foilowing reoson(SeUion 7031.5,B�siness ond A��ttE55 FINAL �
ProlessionsCode): . .. . . - � PRE eNT . --- ---- �BY - � � � ,
❑ BUILOING
I, as owncr ef the properfy, cr my employees wi!h nCDR:55
woges as their sale compensation,will do ihe work and -- -� - - --� � � ► � - , , �
the shucture i:not intended or offered for sale(Section ' ����TY
7044,Business and Professions Code). MOVirIG tEl. �
� I,os owner of the property,am exclusively contracting CONTRACTOR � �� �/��A � .T�6(� �
with licensed toMrattors to construcf the project(Sec- . . ._ _ . . .__. _ �� V d �
tion 7044,Business ond Prafessians Code). AD�RESS � .
REOUIRED TOTAL SETBACK FR M I �
CONSTRUCTION IENDING AGENCY. ._ . - SET BACK .YARD HWY - �PROP.LWE WIDTH . - �
� I hereby affirm thaf Ihere is a tanslroction lending ogency for fRONT ,
Iha performonce of 1ha work for which lhis permil is iswed P.L . -
�(Sec.3097,Civ.C.). Si�E
P.l.
lender's Noma � � .
�.�7� (DAAH Ref.N
Lender's Address - � -- - - P.C.Fee S Permit Fee 1 -
I cerfify thaf I have read this opplicalion and stale that 1he � Issuonce Fee ��v� IDMA P/C M ' �
above informafion is correct.I ogree lo comply with all County invesuga��on Fee rJ�[��1 L .
ordinontes and Slote lows relating�0 6uilding tonslruction, Torol Fee / T�!ti/ IDMA Perm.M . . .
ond hereby au�horize re seNatives af this County to enter �
upo ha obove•men�io roper�spection pu�poses. , � � � � �
r 4�Z�E� . . _ .. _ .. .. .. __ _ . '
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