HomeMy WebLinkAbout1631A (9) � WORCERS'CO.1"•FENSATION DECLARATION � ( '
r1 hereby.o(firrn,�o�� �a�P a cerlificalP o,�o�,e�,,o self qPPLICATION FOR BUILDING PERMIT �
ins�re,"�r a cerlifi[o�e of Workers'Com ensorion Insurance,
o.a cer��fled topy iFereof�Sec.:900,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. Company
� Ceniiied copy is hereby fu�nished. FOR APPLICANT TO FILL IN eu��o�NG /��J.'Jc �y D G/I`c����
nooaess u-(r-t
� Cerlilied copy is filed wilh Ihe counly building inspet• BUiIDING
t�on depanmenl. ADCPF55 � � � � .Q�
Da�c Applicant CITY � 2iv tOCALITY
CERTIFICATE OF EXEMPTION FROM VlORKERS' NO.OF 91DG5. NEAREST �j��nL
COMPENSATION INSURANCE S�ZE CF LOT NOW ON LO� CROSS ST.
�This sedion necd nol be completed i}Ihe permil is for one TRACT !J BLOCK lOT h0. h•AP OOK y PAG° PARCEL
hundred dollors(S1D0�or less.j �j-�^ /y��J -
OwtiFRG�`.�-� �� p, K�C/ .� SEZ01E MAP //_ �,/��
I tr,r�iiy�hat in ihe perfarmance a�the work(or which�his K� f�� NO. y
permil is issued,I shall nol employ any person in ony manner � � SPECinL �y
so ae to beca e s ject l0 1he Vlorkrrs' omp n Lows. ADDRE55 i � � 0 CO CON�1TIONS p
Dale�Applitont ' / i!'� CITY ��`'�O�O ZiP �
NOTI T APPLICANT; I(, of oking fhis Cerli{i[O�e of ARCHI ECTOR TEI. DISTRI�T G40UP iYPE FIRE F�tOCEiSED BY O
FNGINEER M1O. !vST. ZOVE H
Exemption, you should be me svbject fo tha Workr.rs V
Compensolion provisions of the lo6or Code,you must forth- pDDCESS /a � , � W
wi!h c^^.p!y u•i!h ,u;h provisicns or this parmit shall be n-�
deemr.d revoked. TF�� STnTiSiiCAI Cta55iviCA iO4 � A7T. NpQ. (n
C04TRACTCR � NO. Z
UCENSfD CONiRACTORS CECLARATION � �i�, MSS NO. ^Z� DK'ELL.UNIiS
I hereby afiirm ihal I am licensed under provisions of Chaprer 9 ApcRESS NO.
(commrncing with Set�ion 7000)oF Division 3 of Ihr.6usiness and ��� SEN'ER MAP
Professions Coda,and my license is in full(orce and effecl. CiTV �LASS eK � VAIIDATIOH
50.fT. NO.CF h0.CF CHECK
li[e�se Numbe� l�[.Closs SIZE 5704!ES FAMIlIES �M1�
VALUAiION
eo�i�o�io� oare CFSCR�7TION O�WC4K "E'" s Q�� �� '•1 h 3 1 A
� [/ ~0�'/� aoo ❑ , . . .
I am exempt under Sec. ALTER � . • �
B.BP.C.far rh��receon REPAiR ❑ = c
useoF I • •2a5U
oa+e: oenro�
ex�snn�c e:oc. . e ,�a�`_
S�g�0Iu1e AF7�ICANi TEL. fINAL n
OWhER•BUIIDER DECLARATION (PRINT h�� DATE//r �Q � � .-��
1 here6y affirm that I om eYempt(rom the Cemroctcr's Licenee .
law fcr itie lallawing reaecn�Seclicn 7071.5,9veine�s and aoCaE55 FINAL
Pro/ees�o�sCode)� . � gy,V
j�7�' °UIlDI4G _ ,
V� I, os owner of Ihe property, or my employeef wilh A�DR:SS �
�-� wog�s ce thetr sole compense�fon,wI II do�F.e wcrk ond . .:;� , �����+,
ihe structura Is na��n�ended or cffe�ed for sale(Section �OUuiv ,
7044,Busine�s ond Profe�siort�Code�. MOVI�'G TE�. � ��
� I,07 owner af tha properly,am exclusively conirocling CONiRA[TOi NO.
wi!h licensed conlracicn to cons!rucf Ihe projecf(Sec• ApC7E55
tion 7044,8usiness and Pratessions Cade�.
CONSTRl1CTION IEN�ING AGENCY SE7 eA2K YA4� HWY fOTnDROo.�itiE� V W�oiH
I he�eby aifirm�ho��herc is a constr�c�ion lending ogency 1or p�ON�
�hn performonce of Ihe work for which Ihif permit is issued v L.
(5ec.3097,Civ.C.). S��E
P.l.
lender's home
y�� L��.1H Rnf.M
lendrr's Address P.G Fee S Pe•mii fee A �
I ce�iify thof I hove raad this applicaiion and staie tha�the �seua�ce Fee ��'�U IpMA P/C N
obove informotion is correct.I agre.e to comply w�th all County i�.esngar�on Fee 2�J.— �
ordtnvnces and S�a+e laws reloting to building tonslruclion, To�al Fee S lD"�1A Pe.m.M
and herehy oulhorira represr.ntaiiv his Caunly lo cntcr
upan ihe a e- Toned prope.y(or' spetiion purpo s.
� , , �l�l� '/� SEE REVFRSE FOR EXPLANAtORY LANGUACE
Siq�nN.e of Appl��onl or A9e�1
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