HomeMy WebLinkAbout1091A (5) L•JORKERS'CO:".PENSATIOY DECIARATION ' J�
. I hnreby a�f;,m,�a.� ha.< a certifica�e o}�o�,��f,o,a�F APPI.I�'ATION FOR BUILDING PERMIT
insure,or a certiF�coie af Workers'Compensa�ion Insu�ance, 'L�
; ar a ce�t�lied copy ihereof(Sec.9800,lab.C.)
' PolicyNo. Compony � .+NTY OF LOS ANGELES BUILDING AND SAFETY
� � Cer;ified copy Is hereby(urnished. rOR APPLICANT TO FILL IN BUIIDihG O � -
❑ AD7RE55
Cen�fied copy is f�led wirh�he eounry 6u�id�ng inspea BURDING 2 �3 n/ r!/L� L`� ���L� `� ,
��o�depai�meN. AC�4E55 r !�! �-'
Dale APPlicant CITY r W(/ 4�/7K+ ZIC �/ (:, ;p�qLITY ` 1� ��.(\.
CERTIFICATE OF EXEMPTIO!V FROM WORKERS' h0.OF BloGS. n�EnREST
COMFENSATION INSURANCE SiiE CF LOT NOw CN LOT CROSS ST.
(Th�s secr�on need noi be cor„ple�ed if�he pe�mi�if for one n55E5SOR
hundred dollors(5100)er lese.) TRACT BLOCK LOT NO. N,qP 9ppK PAGE PARCEI
e•xnca /-1'r L�C'1�1�,/� no:l'�G'/��S'�?`!(J us�zctie n�n [}
I certify Ihol In Ihe perfermonte of tha work Tor which this ,I�+/ 1� h0. }� O ��
permil is issued,I sholl not employ any perscn in any monner ADD2E55 2i3 03 �/VfL� �[{� SxCIAI O
so es ro beccme subject lo the Vdorker C pensa�ion Laws. � CONDITICNS
�� CITY I �ON � ncJ ZIP V
Date Applican ' qRCHITECT OR TEL. C
NOTICE TO APPIICANT: If, ofi r mo4ing this Ce� ico�e oi D!SiaiCi G40Uv TYPE fiRE �tOCE55.D Bv O
Eaem Ilon, � FNGINfER NO. -�
p you should become sub'ecl �o the Workeri CON ZOhE � U
Campr.nsalion p�ovisions of Ihe labor Code,yo�mus�fonh- p,,,,o«5 ,O � ���„�. .
ith comply with such provisions o� Ihis permit sholl be N TE� STATISTICAI MSS�FiCATiON APT. CONDO, c�j)
deemed revoked. CON7RnCTOR 'I eJ� z
LICENSED CONTRACTORS DECLARATION ��i�. RASS�O.�C'h'ELL,UNITS
I he�eby affirm tho11 am licensed under provisions of Chopler 9 ACDRE55 1�p,
(commenting wiih Sr.c��on 7000)of Division 3 oi tF.r.Business and ��� SEv,'ER MJ1P
PrcFessions Code,and my license is�n iull iorte and effect. CiTY CtASS BK � VALIDATION
SQ.fT.� NO.CF NO.OF CMECK
license Num6er lic.Closs SIZE STORIES FAMilIES OtiE
VALUATION �
CESCR'PTiOV OF Vr'ORC��D t'�2^.KE•T l2xl�'. �� ❑ S ��0��.�
Conlractor pote nn ❑ , ,
�I om e:emp��nder Sec. �W �� �V�N�1 (,J(' �.�/ A�
/f^ A���
B.SP.C.for�his reason ��/// G�--��/��}'ti�il /� � �n12 � f
Date: EY:S:itiC.B!^G. (�'XIS�I'vI/(IJ�.%�?� CFMOI ❑ . .
Signature � APP�I�A4i TEL. FINA{�
OWNcR-6UIlDER D'cCLARATION lertivil n70. pAT��/
I hxreby affirm�ho�I am exempi(rom the Contractor's licenso
law for thc following reoson(Sec�ion 7031.5, Businnss and P.D�PE55 FINA ��� ;� ��,� ��
•Prefes:ior.s Codc): pe�,EN, 8y
�,
� eu�t�in� � �
I, as ownrtr of the properiy, or my employr,es wilh n�Da�55 �� ' ' • 1
war,as es iheir soi�cempemo!icn,will do the work and
�he str�ct�re is no�iniended o�offr.red for soln(Secr�on ����T� r� � � • •'J�1 7 J
7044,Business and Prafessions Code). h�Ov:nG r TEI.
� I,os owner o(IF.e properly,om exclusively conlracling CONiRACT02 I NO. • . -�(;,'j�� �
wiih licensed toNrnctors to construcl 1ho proje[t�Seo- ADDFF55 ��`.C�:—t�
�ion 7044,Business ond Prafessians Codc). .
CONSTRUCTION IEND�NG AGENCY SET BACK YARD HYIY ���ApROP.Lln'E� v� W DTIi
I hereby aI(irm Ihal lhara ie a tons�rut�ion lendinc�apency for fuCNI
ihe performance a/the work for which rhis permii is issued p i.
(S^C.3097.Civ.C.). SIDE
, P.l.
Lender's Name
S LD';A Ref.M
lender's Address P.C.FPn 5 Pe.mit Fee
I cenlfy thor I have read ih�s opplicarion and sta�e tha��he Issuancn Fee U � tD!nn PiC N ' /
obove informolion is conoct.I agrea lo comply with ell Co�nly in.e:i�ganon Fee
ordinantes and Statn lows rr.lnting to building tonerruction, 7o�v1 Fee LD`A4 Perm.M
ond herr.by authorizc reprr.senratives of this Coun�y fo emer
upon n oyove-menlioned p�operly for inspectio purposes.
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