HomeMy WebLinkAbout0979A (5) • VVORKERS'CO".1PFNSATION CECLARATION .
�I hc�eby�,,,�m ihai I hove a cerriFicote e��o�,e�,,o=P�� APPLICATION FOR BUILDING PERMIT �
�nsurr.,o�n cerr�f�co�e of LVorkrrs'Compensorion Insur�nce,
o�o ce���l�ed conv�hernnf(Sec.3@ b.C)
volP, � ��j�3'$'�m a�r� t . Y'�l COUNTY OF LO$ANGELES BUILDING AND SAFETY
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Cc.rif�ed copy�s herehy f�rn�sheA. FOR APPII NT TO FILL IN ADCRESS � �v �. fY�+�'� �N
� Ce�nfiad copy�s kled wuh the c unry buld�nq inspe.o euuoirre , (��� " Y, `�
t�on depa��men�. 3 � nooa[55 l�
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Date ZS���i��o '� 14t���(lGt� uTv Cc✓Np� G✓' z�v :ocnurv
CERTIFICATE OF E%E�!.PTION FROM WORKERS' NO.OF BlDGS. NEnREST
CO�MPENSAT�ON INSURANCE SIZE OF(OT NOw ON!OT CROSS ST. /r R. '
(This sr.clion need nof be completed if Ihe permil is for o�e. �7 ASSESSCR
hundred dollars(SI00)or less.) TRACT /S� BIOLK l0T NO. �fAP BOOC PAGE PARCEL
'� iF �'i/'l �i/ U� ZCNE flAP }
I cr.nNy�hai in ihe Performancr,o(�hc work for which ihh OWnFR �1� �- • /'� /1S NCV�(ovrC}� / �. �,ZQ�?y.C� d
permil is issurd,1 sholl nol employ ony pr.�son�n ony monner � � SPECIAL O
so as to bemme subject 10 Ihe Wor ompensa� Lowi. /' ADDRf55 � ` �/ � � r. C0471TIQN5 V
Oate��pplicaM �Y, �2tc��„ arv � 2/'Tto�'�[ �� z�r p
ARCHIfFCT OR �E�� DISIRICT GROU? TYPE FIRE PROCESSE�BY
NOTICE TO APPLICANT: If, ofter making Ihis Cr.rlificnte o1 FhGiNEER NO. CONST. ZONE W
E.r.m�tion, you should become. subject to Ihe VJorkers'
Compc�saiion pro�isions of fhe lobo�Code,you musf fonn• qD�RF55 1� �
ith comply �th such pro�isions or �his permir zhall bc ,� z
dcemed revoked. L ' TFt ,� CC' STAiISTI�jS��IP.SSIFICAT104 APT. C DO. _
CCNTRACTOZ 1 1 G [� I(/N, � ✓� �/
IICENSED CONTRACTORS OECLARATIOY (/'� / ���, p c[ RA55 NO.�c�DWELI.UNITS
I herr.by o!firm thol I am licensed under provisions o1 Chap�cr 9 �DDRE55 Q/� ` t ' NO. �/�/
(tommr.nc�ng w�ih$ecuon 7000)ol Division 3 of ihe Bus�ness and �i� !.� SEwER�nnv
P�ofess�ons Code,and my license is in(uil lorce and r.ffr.c�. C�T � �S��a�. � C�ASS��/ eK � VAIIDATION
S //�3� 50.Fi. NO.OF NO.OF CHECK
�iCenseNumhP.��/ ��� LIC.��OS! `--� SIZE � STOQ'E$ FAMIfIES ONf
/� � VAIU ION
�� � � %� �ESCRIFiICNOf WORC �G�' NEW � N�
Can�ract '� ate C`— �1 ADD � s �
�I om ewempl under$ec. J `S v �xC � ALTER ❑ ,
8.8P.C.lor ihis reason RFiAi4 � s .
Da�e: USE O� CE",OL ❑ :Q�j�7.�i�{
FXISTING BIDG.
Signalur� l.PPLICANT 7E1. FIHAL ' • • •
OWfVER-BUILDER CECLARATION (FRINT) NO. DATE �� '�� � �
�hereby affirrtt thot I om erempt fram thr.Conirac�or's litense
low for the lollowing rcason(Section 7CJ1.5,6usiness ond PDD?E55 FINAL � � • •7':,?�
Pro(essions Code)� RunD�N3 � By • • •7�.�v�
� I, os owner of Iha propeny, or my emptoyees wilh a0o-FS5 �� '
wages as their sole compensat�on,will do ihe work and , ��.� Fy—�3
�he srructure is noi intr,nded or off>red(or sole(Settion LOfiILITY
7044,Bus�ness and Profess�ons Code). MOv:NG iFl.
� I,as owner ot ihe properly,om exclusirely tontrott�ng COti1RnCT0R NO. �/
with licertsed con�roctors to cons!ruct�he projr.tr(Sec- qo�ce55 �""'" Tr�9 �
iion 704a,Business and Profe.ssions Codr,).
CONSTRUCTION LENDING AGEhCY SET�BaCK YACD HWV �U�ADRO�l Nf V WIDTH
I hereby al(irm thot ihere�s a cons�ruc�io�lendin9 ogency!or (pUry�
ihe pe�formence of ihe work fo�which�h�s permit is�ssued a�.
(Se[.91�7.Civ.C.�. SiOE
P.�.
Lender's Nome �
G �.7`S iorra Rnf.M
Lendcr's Address v.0 Fee S � ve�m�r Fee �-y� ,
I certi(y that I have read this applicotion and slolr,thol the Issuonce Fee ��`�V lD�4lA v/C M
obove information is correci.I ngree�o tomply with oll County Inves•�ga+�on Fee (�
ordinantes and S�a�e lows rela7int�l0 6uilding construction, To�ol Fee !�� LDMA Perm.M
and he y a or�ze rep�eseptaiives of this Couniy lo cnter
u�� ah6 menS�onP Qroperry for inspection purposes.
x // ��•��`. SEE NEVERSE FOR F%�LAHATORY IAHGUAGE
S�gnolvre ol Appl�mn�or Agenl pn�e
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