HomeMy WebLinkAbout1551A )1'ORKERS'CO!P.FENSATION OECLARATION
I hr�rby o����m rhal I hevr���,,,�;�o,�oF�o�,��,,o,��� APPf.ICATION FOR BUILDING PERMIT �
msure,o.a cen�lita�e of Wor4ers'Compansalion Insu�once,
cr�o ccrr�lird ccoy�hercof(Sec.3300,Lab.C.� COUNTY OF LOS ANGELES BUILOING AND SAPETY
Palicy No. Compony BU�tC'NG
� Ccri�l+ed copy is hcreby fur��shed. FOR APPLICANT i0 FILL IN ADD7E55
� ,CrrGlied cepy�s f�ed with ihe counry huild+ng inspec- BUi1D�NG '
lion Acpnrfinenr. AD'J�E55 _���1/�
DOIC Applicant CITY {JI��O/�I��,� 71V' �I/Ei l IOCAtITY .0
NO.OF BlDGS. N'.AREST
CERTIFICATE OF EXEMPTION FROM VJORKER$' S�ZE O�lOi NOv�I ON lOT CRO55 ST. ti • �}[
CO1dPEN5ATION INSURANCE -�—
�This seci�on necd not be tomplcied if Ihe pe�m�1 is for one ASSESSOR '
hv�dred dollors(5100)ar ICSS.� TRACT OLOCK LOi NO. /J�AP P.00K PAGE PARCFL
O`h'NER
C ��' f USE ZONE �N }
I te!rlily ihot in ihe�crformoncn.of the�ork lor wh' i is �� n.
permi��s iss�ed,I sholl not employ ony p son any nnn . 6 S°E�iA� U
so as l0 6eco ,su�[t lo Ihe�'✓o�k i Om�rnsali n La �DDRE55 p� sV PCa�!ei��. �.� CpNDITIONS
�) �d. aTr n� i3a, ziv C� �
�/ Do1N Appli[ant ARCHITECTC+' TEL O
J1 NOTICE TO PPIICANT: If, a(�er m ng this Ce�����ca of DISiRiCI GROU7 TyCE F14E PROCESSED BY �"'
E.emp�ion, you should become subjen �o �he Wa ke�i ENG�!.FfR N0� CCY$T, . 20N W
Cemp�^•.�'icn provisiars cf the labor Codr.,you mus�(orth- pDpRF55 • � �"
wi�h comply w'�h suth provisions or Ihis permii sholl be TEI. $TATISiICAL QASSIFICATION AVT, COt+00. Z
deemr.d revokpd. �04iRACTOR NO. —
IICENSED CONTRACTORS DECIARATION �i�. RA55 NO. DwEIL.Uv1T5
I hereby ollirm thot I am licensed�ndr.r prov�s�o�s o�Chcp�er 9 A��RE55 Np. �w,���P
�tommrncing wi�h$ection 7000)of Dirision�of the B�siness ond liC.
Professeons Code,nnd my license is in lull Iorcr,ond elfect. CiiV Cta55 BK � VALIDATION
SO.FT. NO.OF NO.CF CHFCK
licensr.Numher Li[.CIo55 SIIE STO4iE5 FA.MIL�ES O�E
VALUATION an
DESCRIPi104 OF WCRK �,� N'w ❑ 3
CoNraclor Dalr. ACD = `" ��� ,
�I am ezempt under Sec. . � �
ALTER
B.BP.C.for ihi�reason REPn!R ❑ s . '
DOIC: �SE OF DEI.tiOL
E%ISTING OICG. � :�� 5 J� l�i
AFMIGiNi TFI.
$ignalurr. FR:NTI NO. FINa e • •
OWNER-6UILDER DECLARATION DAT �/, �' � ' �
I he.eby aff�rrtl iha�I om ezempt from�hc Controctor's Litense
law for Ihr.(ollowinp reoson(S^ction 7071.5, Businrss and /OCoE55 FINAL � • �U�.G;
Professions CodeJ: _ .__ , a�ie_!n� B1' a . c —
❑ BU'LDiNG � "��^—
I, os owner of ihe p.cpe.ty, or my employees with aDo4e55 .i
agez as ihr.i.sole compensonon,will do�he work and �� � �1 0� ,i—";S
the struc�ure is nal intendcd or o((ered for sole(Set�ion �aA�iTY
7044,Business ond ProFessions Code). fAOVING TFI.
� I,os owner o(the proper�y,am e.cl�sirely contracrfng CONTRaCTOR NO.
wilh licensed tonlractors to conslrucf Ihe prajetl(SeO . qD�RE55
iion 7044,Dus�ness and Professions Code).
CONSTR�GTION LEND�NG AGENCY SEi�Bq�K Y�RD NWY ���Apppp�iNE� W!D7FI
I hereby af(irm thar ihere is a cons+ruction Ir.nding agency For f RCu�
Ihe performvnce o�IFe work(or which Ihis pe�mit is is�ued n.t.
(Sr.C.J097,Crv.C.). SICE
v.�.
Lendei s Nome
lDMA Rel.M
Lender's Address P.C.Fee S Pe�m�e Fe. J
I crnify ihot I ho�e read Ihis appli tion ond sro�e ihot Ihe Nwonce Fee � l�"M P/C M ,
above informm�on is corre .I ,�e td Comply wilh oll Counly � in.es��ga��on Fee
ord�nOnCCS Ond 510�9�a s relati g�o uilding conskuction, To+nl Fee IDti+A Perm.M
and here authorire r p.esem iive of�h�s County�o enter
vpon�he above� nti f or ins ncfion purposes. ��q)
� � _ 7'�Y(l�/ SFE REVERSE FOR EX�IANATORY LANGUAGF
� naNre ol Apphconl�r Agr.M Dole
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