HomeMy WebLinkAbout1315A .. WORKERS'COMPENSATION DECLARATION - � � -. L '
� insureborpfteriifca'feofWokers''Compensatioolnsuranelf APPLICATIQN FOR BUILDING PERMIT U
or o certified topy the�eof(Set.3900,Lab.C.� � � - � � '
COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. Campany /� /�
O Cerrified copy�s hereby furnished. FOR APPLICANT TO FILL IN npoa¢ss �` �9�v 3 �G.�-�/�+u-.��a K�h•
�- Certified2opy is filed wiih Ihe county building inspec BUnDwG !.. � /� p
tion depo�tment. ADDRE55 �l� � �6t �\l�l� .�7•
Dote Applimnl CiTY � 217 lU LOCALITV
CERTIFICATE OF EXEMPTION FROM WORKERS' � � � . NO.OF BLDGS.. NEAREST . ,
COMPENSATION INSURANCE � - S�zE OF Lor Now oN Loi � CROSS Si.
�This setfion need nol be tompleled if Ihe permit is for one TRACt d BLOCK LOT NO: M�qP�Bppl( � PAGE PARCEL
hundred dollars(5100)or lesz.) . p�(
OWNERL S �CP:TEO. I -Ci�u�� U ZONE �P y �� � r!(f
I certi(y�hol�in the perimmonce of Ihe work for which Ihiz r NO. aCN `�'V }
pe�mil is issued,I shall nat employ ony person in any manner �1 (] � �E��A� , � O
so as to become subject lo fhe W ers'Compe solion aws. ' � ADDRE55 OC 7� I �l� � CONDITIONS
` _ .'- . . Q,_ CITY D���{ ZIP` � � �.
,{�ale�Applican ARCHITEC7 OR TEI.
\NOTICE TO APPUCANT:��If, after making�Ihis Certifitete of ENGWEER N� OISTRIQ GROUP TYPE FIRE PROCESSED BY O
E:emption, you shou�d become svbject�to the Wor4ers' '` CONST. ZONE V
Compensatian provisions of the Labor Code,you must forlh- qpokE55 v �� W
wifh comply wilh such provisions or Ihis pe�mil sholl be .. . .'` TEL. STATISTICAL GLASSiFICATION APT. CON�O. tn
deemed revoked. .. CONTRACTOR �W NO. Z
UCENSED CONTRACTORS DECLARATION _. �i�, ,, MSS NO. DWELL.UNiTS � �
I hereby offi�m thol I om licensed under provisions of Chopter 9 ADORESS NO. ��R�P
(commencing with Section 7000)of Division 3 of the Bvsiness and tIC.
ProFessions Code,ond my license is in full force and effect. CITY� QA55 � BK � � - VAIIDATION
. , • _ � - ..., $Q.FT. �]�,-,� NO.OP NO.OF CHECK .
License Nvmber� Li[.Class SIZE o�+7' " S70RIE5 � FAMILIES ONE '
VALUATION �
Controttor Date OESCRIMION OF WORK � A D ❑O = .+1 ��� � -
� - .ZC6a zd' � ,
I om exempt�nder Sec. ALTER� � �1 3 1.5 A
B.BP.C.for Ihis reGson � ItEPAIR � s . . . #• • • • ���
USE OF �
� � � �� Dale: � - � � DEMOL
EXISTING BLDG. �
..Signalure' . . . . APPLICANT tE�. FINAL I � •4 9.2 5 .
OWNER-BUIIDER DECLARATION PRiNT �' DATE "f -� . � s
I hereby affirm that I am eaempf from the Con�mcfor's Licanse � - - • •�4 9.2 5 0
Law for the following reason(Settio�7031.5, 8�siness and ADDRE55 FINAL
Professions Code):- � PriE ENi � By a 9.�� —8$
BUILDING
I, as owner of the property, or my employees with nDDrtESS
�� woges as�heir sole compensation,will do�he work ond ,
the st�ucture is no�infended or offered for sale(Section lOC/�li7Y
7044,Business and Professions Code). - MOVING TEL.
� I,as owner of Ihe property,am extlusively conlracting CONiRACTOR NO. �
with licensed contraUors to mnsvutl the praject(Sec- qDDRE55 � - � � � ��� � � � � � �
tion 7044,Business and Pro{essions CodeJ. � .
� CONSTRUCiION IENDING AGENCY � � -SEQBnCK YARD HWY T�TAp OTP.UNE wi�TH �
I hereby afFirm that thera is a consnuc�ion lending agency for FRONT ��
the periormance of Ihe work for which this permit is issued F.L.
(Sec.3097,Civ.C.). Sioe �
P.L.
lende/s Name �DMA Ref.X
. .. P.C.Fee S . Permit Fee
Lender's Address r �
I certify that I have read ihis opplication and s�ata that the issuonce Fee �� �`�� LDMA P/C B .
obove information ie torrett.I o9ree to tompiy with all County invesr�ga�ion Fee -
ordinonces and S1ofe laws relaling to 6uilding conslruction, Total Fce � Z� IDMA Parm.X .
an ereby autho�i a repres ntatives of this Coonly to enter -
' up tha above-me ioned roperty fo�inspettion p�rposes.
`(.Q _� /-�'g SEE REVERSE FOR E)(PIANATORY LANGUAGE �
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