HomeMy WebLinkAbout1180A 1181A iWORKERS'COMPENSATION DECIARATIpN
, `'hereby,cffirm tha�1 hove a cenificate of conunl to telf qpp��CAT10iV FOR BUILDING PERMIT
insure,or o cer�ifitote of Woikers'Compensation Insurance,
I ar o cenified copy thereof(S�c.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING ANp SAFETY
�. policyNo. Compony BU��D7NG ��.
� Cen'rf�ed copy�s hereby fm�+shed. FOR APPLICANT TO FILL IN AppqEu 2/(77 /��7�i��n
� Cer�ified copy ia filad with iha county building inspee- owiDtNG /►���+3 ����� -71/A�O�f, g�.�•
fion depar�menf. A�DRE55 L. p S✓
Oale Applicont CITY •J/��O�O 4Xfh� iIP LOGtITY
CERTIfICATE OF EXEMPTION PROM WORKERS' �'�et�s� � �R�S$7. �1� CA-N`1'� '
COMPENSATIOtJ INSURANCE SiZF OF l0T . NOMi Onl iAT
�This seCtion nead nol be completed if fhe permit is fior one ASSESSOR
hundred do�lars(E10p)or 1e65.) TRA�T BtOCK LOT NO. MAP BOOK PAGE PARCFI
�j}� �g TEt.A 4_Z� USF ZONE �P / � 2
1 certify thol in the performance af the wark for which thia OWNER rr'rin��NVc�� NO.'7'7 No. .�'=.,33 �
psrmit is issued,1 sholl nol emp�oy any person in any monner �,�j SPEC�AL t
w as to become subjacf ro Ihe Warken'Compeowtion laws. AooRE55�7U'�� m���E'� SU�r�f� C P� CONDiTIOnlS U;
cRr�ieY/NE ziv q't/� d• u r-v� �
Dafe AppllcoN ARCHITER OR TE�� / DISTRICf GROUV TYPF fIRE OCE55 D 8Y O
NOTICE TO APPUCANT: !f, ofter making this Certifimro of EMGINEER Qw��� �.�7g�2� n - ro�� z� V
EKempiion, you ahould bemma aub�ed to Ihe Workers' KaL `f w
Compenwlion pravisions af the labor Gode,yau muee forth- ApDRESS a J ���� '�-
Wilh COmp�y with su[h p10`/iSlons Or /hi5 permit ahall ba TEt.yyiy/Jn.�n STATISTICAL C1A551FICATION �T� ��N�� Z
deemad re�oked. �pPIfRA[TpR -Q /✓� NO!'p/'TG�/�R•r � �
LICENSED CONTRACTORS DECIARAiION IIC. ���'�""""'���
I hereby aifirm thw I om licensad undar provisions of Chap�er 9 .aD�RESS NO. ��R�p
(rommencirg wilh Section 7000)of Division 3 of tha Busineu ond LiC.
Profeasions Code,and my iicense is in fuil forca ond effect. oiv M55 eK � �� VAUDATION
� SCi.fT. �^ HO.OF NO.OF CHECK
Litense Number Lia Clos• S12E �J STORIES 2 PAMIL�ES �E
. ❑ VALUATION �
OESCRIPTION OF WORK Ll�i¢u+ NEW
Conrracror Date s ��� ,
�I om exempt under Sec. � � �hp � �1 1 �O A
� #�'. � • �2.z.
B.BP.C.for�his reason T� E .G�L�M REPAIR L l
uo�e: ezssrwc awc. [��F/C.E$ oema ❑ I • •3 2 9 4
$i naNre APPLICANT-�y 7EL. ..�A PINAI • e a�j 2,�'���
9 PRIM1 rN�'FIA��� N0.4/'r�?�d , .
OWNER-BUILDER DECtARATiON DATE
I hereby offirm that I am exempt from�he Contracror's License A��E��?�j/�2�f��{.L(, $/f/JF/Oy,�,1�/� flNAI'/� �+ �e'� 4—�7
Law fo��he followirg reoaon(Sectio�7031.5,BusineEs and
ProFessiOns COde�[ FCESENT dY V v =�,1 1 &1 A
❑ BURD�NG
I,as owner of the p�operly, o� my amployees wilh �. ApDRE55
woges as Iheir sole compensation,will do ihe work vnd � �� � � � �}
' 1he siructure is not intended or offered fw aale�Section LOCAl1TY
J6t4,Busina3s ond 9rofessiona Code}. �vANNG TEI. � • •4 4.2 5
� I,oa owner of Ihe propeKy,am exclusively[onNacling CONTRACTOR �� � �
with licensed tontroctore 7o construct fhe ptoject(5ec•' •4 9.2 5 c=.�
AODItE55
tion 7041,Business and Rofesaiens Code). I Q� �l�8 7
WNSTRUCfiON LEND�NG AGENCY SFT�BAOC YARD HWY TOTAL�uNE WIDTH
I hareby aff'�rm thef Ihere is o construction lending agency for FRON7
Ihe perfumance of the work fa which thia permit is iss�ed v.l. .
(sec.3W7,civ.c.J. sioE - , ;'�r, ;:,,�
v.�. �
Lender's Name ���E �{ p p- IpMA Ref.N
$ �b�� P.C.Fse S �� ! Pxm�t Fae �8'��7 �
Lender's Address �
� I certify thoi 1 have reod thie opplicarion and swro that the iwwncs Fes � WAM P/G M
o6ove information is corcect.I ogroe ta comply wNh all Couny Invsst{goNon Fae
$ o dinoncaa Stafe lawe rolm�ng to building mnsfrudion, iehl Fss 2� t�MA P«m.N
R ereby o horiz rsprsse ' f this County to eMer
� he a v - ned pr er o inspeclio�purpone '
� �g'' SEE REVEIKE FOR E1[RANIhTORY lAN6UAGE
ignoluro of ApP Kanl or Age De
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