HomeMy WebLinkAbout1594A WORKERS'COMPENSATION DECLARATION . . f - �}
I here6y affirm ihat I have a tertifimte of consent to self � LS
��,��a,or a certifitata of Worke�s'Compensalion lnsvrante, �P P L I CAT I O N-F O R �B U I L D I N G P E RM I T
o�a certified copy thereof(Sec.3800,tab.C.) . COUNTY OF.LOS ANGELES__ ��'i. . BUILDING AND SAFETY
PolityNo. �Company BUiLDiNG
� Certiiied mpy is he.eby furn�shed. FQR APPLICANT TO FILL W - aooRess a�9oZ
� Certified copy is flled with the cooNy buildi�g inspec- 8UIl0ING I .
, tion deparimeM, � . . A�DRESS � .� ,�,�p " LUCAIIN .
NEAREST /.' .
Date Applfmnt CITY W P ZIP CROSS ST. l�n�
� CERTIFICATE OF EXEMPTION FROM WORKERS � � NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T MAP BOOK � AGE PARCEL
(This settion need not be tomple�ed if the permit is for one use ZONE nwP /aV..-� �� ,
hundred dollars(E100)or less.) rancr e�ocx LOT NO. � No.
. � TEt. �n � SFECIAL �-
I certify that In the performante o/Ihe work for which this OWNER � Np. 7 C71. �� � CON�ITIONS 0-
permit is issued,I sholl nat employ any pBrSon In any manner ' ' � - - - /� �� DISTRICT GROUP TYPE FIRE PROCESSED BY 0 _
so as to become sub�ect to Ihe Worke,s'Compansation Laws. ADDRE55 y y I �� CONST.,1// ZONE �
. . . , . . �.. .. 1' `.J
Date -� � � Applicanf - ' � � CIN. .G �- .. ..ZIP / STATISTiCAIClAS51FIG4TION APT. NDO. � O
NOTICE TO APPLICANT: If,ofter making Ihis Certificate of ARCHITECi OR TEL. _9 � � � �V
ENGINEER -NO. � ��qu N0�-`/ DWELL VNIT$ W
�Exempflon, you ahould become sobjecf to the Worken' p,
Campensation provisions of the lobor Code,you most forfh- . .. . u1
ADDRE55- - � �� -� ��------ �- -r SEWERMNP
with.comply wilh such provisions or this permit shall be � �
deemed revoked. - � �pMRAC70R .. NO. �� ��BK. PG,- VALIDATION
LICENSED CONTRACTORS DECUIRATION �i�
I hereby eHirm thot I om licensed ander provisions o(Chapter9 ADDRE55 NO. ��,VAIUATION �-
(mmmencirg with Section 7000)of Division 3 of the Business and �� ��� � . �
Professlom Code,and my license is in full forte ond effetl. GiY CW55 ���E�QQQ -� ,, . .
" Sq.Fi NO.OF NO.OF CMECK .-..._ . _. .
Li[ense NUmbef �LiG C�oss SIZE . Q STOR�ES FAMIUES � ; ONE '
. � . . - . . . _ . _. /. N�._❑ E - - . .
CoMfattof D�ta OESCRIPfION OF WORK . � - ' '
� � ' . c . ADD� . -....
�I am exempt onder$ee. ALTER � � FINAL - - ^� ����.a � .
B.&P.C.for this rcason . . .... .. . .. . . ... ...-- REPAiR � DATE�—�'�-�� ���.• . . a ' ,
. � . . . Data: USE OF . � . DEMOL.❑ � FINAI . .
ewsriric aioc. — _ _ ar I • 1 1 1.7 5
Signafure ' . . . . ' APPLICANT TEL.
OWNER-BUILDERDECL4RATION �WT S .NO.S � y ' -" - �
1 hereby aifirm that I am exempt from the Contracror's License � • ' � � �.�'S�
law for the followfng,reason(Section 7031.5,Business and ADORESS 1 �- - - � � �
0�.30-83
� ProfessionsCode): � . � vueSeNi ' . ._ ... _ . . . .. . _ .
\f"1 BUILDING _ __ .___._.. ___ _ _ . __.. __..
n�� I, as owner of tbe property, or my employees with A�DRE55
wages as their sole compensation,will do the work and . . ' . � .
. � the sfructura is not IMended or offered for sole(Setlion -- ����TY . . . . . .. .__. ' . . ..
7044,Business ond Profession:Coda). MOVING TEI. .. . .
� I,as owner of fhe properry,am axclus(vely[ontracting NTRACTOR NO. ' - . � .
with Iicensed conlroctors fo canstrucf the pro�ecf($ee- ADDRE55 �
tion 7044,0usiness and Professions Code). =� ' � � .
� � REQUIRED TOTAI SETBAIX FROM EXIST.
CONSTRUCTION IENDING AGENCY SET BnCK YARD HWY pR07.LINE WiDiH ,► . ' � '
I hereby offirm that there is a con:truction lending agency for . FRONt � �- � � - -� � ' . - - .
the parformance of the work for which Ihis permit is issued p.L. .
�SeC.3097.Clv.C.). � � SIDE . " � �
_ . . _ . . . .. P.L - . . _._ ._._._. _. _._ . . .__'_. .. .� ..
lender's Nome � , __-\�-���
—.: ,..
. . . .. . . _ .. __ . . .. .
P.C.Fee E Permit Fee ��ar
Lendei s Address . � - _ � � �
..I terti that I have read ihia a lication and sfate ihat the . . . � : . .� .. - ---.. . .�. . �U. .�O. .•.. .':� � . .. � . . ._. .
fY PP Iasuan<e Fee � � �
obove informarion is correct.I agree to comply with oll Counry Investigarion Fee . �
-ordinances and Sto�e lowa relating to building constroction, -� � Torol Fee /��•�J �
and hereby au�horiza rapresantativas of this Counry to enter ., .
upon the above- tioned property for inspec�ion purposes. � � - � - �� � � �- � - - � ��-�- � - - �
� ^ O.�� , SFE REVFRSE�FOR E%PIANATORY UNGUJICE .__ . . , ,
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