HomeMy WebLinkAbout1180A 1181A (5) iWORKERS'COMPENSATION DECIARATIpN
, `'here6y,cffirm tha�1 hova a cenificate of�o�u�,�a,a,f qpp��CAT10N FOR BUILDING PERMIT
insure,or o cer�ifitote of Woikers'Compensation Insurance,
I ar o certified copy thereof(S�c.3800,lab.C.) COUNTY OF LOS ANGELES BU1LDiNG ANp SAFETY
�. policyNo. Compony BU��D�NG ��.
� Cen�4�ed copy�s hereby fur��shed. FOR APPLICANT TO FILL IN AppREu 2/(7 f ��7�i+1��IZ
� Cer�ified copy is filad with iha county building inspec- owiDtNG /►���� ����� -71/R y,l��� gR.�•
Iion depar�menf. A�DRE55 L. S✓ /��^'
Da1e Applicont CITY •J/"t�O�O 4.7'fh� iIP LOGtITY
CERTIfICATE OF EXEMPTION PROM WORKERS' �'�et�s� � �R�S$7. �A CA-N`�o� '
COMPENSATIOtJ INSURANCE SiZF OF l0T . NOMr Onl iAT
�This seCtion nead nol be completed if fhe permit is fior one ASSESSOR
hundred do�lars(E10p)or 1e65.) TRA�T BtOCK LOT NO. MAP BOOK PAGE PARCFI
�iTNFi,u�� No.474-Zc� USE ZONE oP / �-g=3 33
1 certify thol in the performance af the wark for which thia OWNER }'^
psrmit is issued,1 sholl nol employ any person in any monner �,�j i
w as to become subjacf to Ihe Worken'Compe�wtion laws. AooRE55�7U'�� m���E'� SU���f� C P� CONDiTIOnlS iL
crtrTieY/NE ziv 9271� d• u �v� ��
Dafe AppllcoN ARCHITER OR TE�� / DISTRICf GROUV TYPF fIRE OCE55 D BY O
NOTICE TO APPUCANT: !f, oftm making this Certifimte oi �7.�GINEER �w��� ����g�2� n _ CONS� Z� V
EKempiion, you ahould bemma sub�ed to Ihe Workers' � I(_f `f W
Companwlion provisions af the labor Gode,yau muee forth- ApDRESS a '�'� ���� '0-
Wilh [Omp�y with suth p10`/iSlons Or /hi5 permit ahall ba TEt.//y�y STATISTIG4L ClOuSIFICATION APT. CON00. N
deemad re�oked. �pPIfRA[TpR g /✓� NO!t/'T� Z
LICENSED CONTRACTORS DECIARAiION IIC. ���' � ��'���
I hereby aifirm thm I om licensad undar provisions af Chap�er 9 .>D�RESS NO. ��R�p
(rommencirg wilh Section 7000)of Division 3 of tha Business ond LiC.
Profeasions Code,and my iicense is in fuil forca ond efFect. oiv MS5 eK � �� VAUDATION
� SCi.fT. �^ NO.OF NO.OF CHECK
Litense Number Lia Clos• S12E /J STORIES 2 PAMIL�ES �E
. ❑ VALUATION �
OESCRIPTION OF WORK Gl�i¢u+ NEW /!���
Conr.ocror Date s ��"'" � ,
�I om exempt under Sec. � � �hp � �1 1 �O A
B.&P.C.fo��his reason T� E .G�L�M REPAIR �� � �+• • • •2�
uo�e: ezssrwc awc. [��F/C.E$ oema ❑ 1 • •3 2 9 4
$ignaNre APPLICANT-t�. f� 7EL. �s�1 PINAI • e a�j 2,�'���
OWNER-BUILDER DEQARATION wriM1 rffTN'FldX�••� NO.Q/`*�?�d DATE
I hereby offirm that I am exempt from ihe Contracror's License Ap�REu�?6/�2"`��{.j,L S�f/j�/�,/�r�,Y/� flNAI'/� � �e'� 4—�7
Law fo��he followirg reoaon(Sectio�7031.5,B�sineSs and
Professions Code�� FReSE�vi dY V v =',1 1 &1 A
❑ BURD�NG
I,as owner of the p�operly, o� my amployees wilh �. ApDRE55
wages as Iheir sole compensation,will do iha work vnd � #' � • • •�
' 1he siructure is not intended or offered fw aale�Section LOCAl1TY
J044,Busincas 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(Seo •4 9.2 5 c=.�
AODItE55
tion 7041,Business and Profesaiens Code). I Q� �l�8 7
WNSTRUCTION LEND�NG AGENCY SET�BACK YARD HWY TO7AL�UNE WIDTH
1 hareby aff'�rm thef Ihere is o construction lending agency for FRON7
Ihe perfumance of ihe work fa which thia permit is iesued v.l. .
(sec.3W7,civ.c.J. sioE - , ;'�r, ;:,,�
v.�. �
Lender's Name ���E �{ p IpMA Ref.N
$ �b�� P.C.Fse S �� ! Pxm�t Fae �8'�� �
Lsnder's Address �
� I certify thoi 1 hove reod thie opplicarion and swro that the iwwncs Fee � WAM P/G M
o6ove information is corcect.I ogrse ta comply wNh oll Couny Inrost{goNon Fae
$ o dinoncaa Stafe laws rolming to building consfrucfion, iehl Fss 2� t�MA Pxm.N
R �eby o horiz rsprsse ' f this County to eMer
� he a v - ned pr er o inspeclio�purpone '
� �g'' SEE REVEIKE FOR E1[fIANIhTORY lAN6UAGE
ignoluro of ApP Kan1 or Age De
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