HomeMy WebLinkAbout1044A (5) V!O�KERS'CO"�?ENSATION DECLARATICN r� �
I her�•by o(firm ihar I have a�e�,;�;�o,P of�o�,e�„o,e�� � APPLICATION FOR BUILDING PERMIT �j
insure,or a cnrtificoie!o}Vlorkcri Compert<a�ion Insurante,
or a crri�fied copY thereof�Sec.3900,Lab.C.� COUNTY OF LO$ANGELES BUILDING AND SAFETY
P�olity Na. Company
Cenificd copy is hereby furnishr.d. FOR APPLICANT TO FILL IN BUIIDiNG .� ``'> f�
no�R¢ss II I ,ei�t'--��,✓Y��-y� FFIi✓
� Cen�find copy ro filed wiih the couny build�ng inspr.c• BURDING /� / "A�l_�l�,�^./�/� / ,(/ 2
�ion dr,pa��mem. nDDB:SS �! J«��LV// /` �„�
Da�e Applitoni CiTY �N/J Ziv �({�� IO�AIITY
CE471FiCATE OF ExEMPT10N FROM WORKERS' J � NO.OF BLDGS. .+:EAREST � �\�i
COMPENSATION INSURANCE SIZE O�lOT i X NOW ON lOi I �RO55 ST. G � y/�J �'�'� '
(Th�s section need no�be tomplr.ted if the pr.rmit is for one /� nSSESSOR
hvndred dollors(SI00)ar less.) TRACT Y BLOGK L T NO. !AAP 90dC 7AGE 7ARCEL
y� 1 fi � f•fE4 E IONE 1fAP t
I cern(y ihoi in the periormance oF the work(or which this OwhFR��C "I � 'o.��� � Np. � r-
permif is issued,I shall nof employ any person in ony monner � � �� 0 � SP'C�AL �
so as to 6e mr.subject to the Workr.rs'Compa saliop ws. AD�RE55 �` �^r! CONDITIONS 0
�Daie �• '���''". �c X ,/ cirv J/�/11���J �(.t-� 2iv r�7 Lv
L Appli[ant �. ARCHITECT OR TEL.
NOT�CE TO AF?IICANir If, afr rr�o�i �his Ceni icatr. of �:SiRiCT GROUP ttPE Fi4E PROCt55ED BY O
Eaemption, you should beco�ne� �n to the Workers FNGih'fER � 7 h0. �ONSf. ZONE � U
Compensalion provisions of th�Lebor Code,you musl forlh- ���5� �,�1/jJ . �T� ,��� �+1
wi�h comply wifh such p�ovis�ons or ihis permit sholl br. �u �-
deemed revoked. �/ TE�� STaTiSTiCAL ClA55iFiCATi , APt. CovDp. V)
CONTRACTOR �(.I/" NO. �/ Z
UCENSED CCNTRACTORS CECIl�RATION ��� G1A55 NO.,_S='LDvhIL.V^�ii5
I hereby o!Fi�m rhoi I am licensr.d under provisions of Chop�^r 9 aDD4E55 NO.
(CommenNng wi!h Seuion 7000)of D�v�s�on 3 of thc 8�siness and ��� SEW4R MAP
PrcFessions Code,ond my license is in full force and effett. CiTY Cin55 4K � VALIDATION
SO.FT. ' !.'O.OF k0.OF CMECK
Li[��SONVmbPr LiC.Class SRE STOR!E$ � FAMItIfS I ONE
VALU/TIQN
OESCRIPTIGN OF Wpqr NEVI �
C❑onhnClO� Dale " n� � I L� �/����� ADD s ��� '
I am exemp�under Set. U �� �
ALTER
B.BP.C.for this reason REPAIR � f
Dafe: USE CF C'�•.a ❑ '� Q/i,rl i
E%iSTING BIDG.
APRIU4NT TFL. /' �
Signoture (c2iM�Se J'�iGE'�'(jE ,p ��t� FINAL �� i� • • • • • �
OWNER•BUILDER DECLARATION DATE�-���
I hereby aff�rm�ha�I am e.empt from ihe Caniroctor's l�cense / � • •,�,(y 7 j
low far ihc following reoson(Sec�ion 7031.5,Business and ADDaE55 �� FINAL �-�
Professions Cadc): �E ti � �- 8Y �L�'" • . .3 h 7 5�
—❑ ����o�N� �-I P_P�/'.r�fr_c�'ou0 .�.�.
s I, as owner of the propnrty, or my employees wiih nCDQESS /,n�!r O�C v-��
wogc�es Ihcir solc tompenso'ion,will do ihe work and ��q��TV �4 7""�''� . 1`�� ,
ihe s+ructvre is ner intended or offered ior sale(Secrion
70aa,Bus�nees ond Proicssions Code�. rr.owNc iEt.
� I,as owner o(�ha praperry,om eKclusivr.ly con�rauing CCNirtnCTOR NO.
with litensed co�haclors to tonllrucl�tie projetr(Sec- qD^ZESS
iion 70<4,pusiness and Profess�ons Code). �
CONSTRUCTION LENDING AGENCY SET BnCc �AR� HWY 1p1Ap40P.iih� � W�Diii
I hereby olf�rm thai�he�e is a cons!ruction lending ogency for �;�py�
�he periormance of 1he work for which fhis permi�is issued P.L.
(Sec.3097,Civ.C.). SiCE
v.�.
lender's Name
�/. ys-- lDNJ1 Re(.X
P.0 Fee S Pe•mi1 Fee �o '
���d�.•:add«:s
I certify thot I hava read this eppllcarion and s!ate iha�the �sv�o�ce Fee /�'� io.M.4 P/C M
above informarion is correci.I agree to comply wiih all Counry in�eci�gaiion Fee / -f L�
ord�nances and Siota laws relating lo building construttien, Toia1 Fee �(O� / J 10.4L4 Perm.M
and,hereby authwize represemarives of ih�s Coun�y+o enter
/upod ihn'hb6ve4neniio�d p.ope«y�or impeclion pvrposee.
��`�:�////���G�� �/L 3 SEF REVERSE FOR El[PIANATORY UNGUAGE �
aro.n af Ap_�N or AgeM Dole
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