HomeMy WebLinkAbout1042A NURKERS'COh'.PENSATION DECLARA710N N"�' `�� �
I herr.hy offirm ihal I ha�e o«.,��;�o,�oF�o�,��„o,��� APPLICATION FOR BUILDING PERMIT
Insure,or a cc.�ilica�r.of Workeri Compensation Insuronce,
or a cer�ified copy thereof(Sec.3800,tob.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poli�yNo. Campany
� Ce�iHied co y lurnishad. FOR APPLICANT TO FILL IN eunoiyG 5 � I �1�� �ti
py is hereb
ADCRES$
� 'Cenified copy is(iled wiih the county bu�ld�ng Inspec• BUitD;'�G� �/�_ n
tian dPparlmC��. P.CCRE55 f �� ���T�/�'![ �` �.� i
Da�e Appli[anl CITY f vM7y�'� � ` ZiP �7�0� IOCAIITY .
CERTIFICATE OF EXEk.PTION FROM WORKERS' `»l ' rv0.OF atoGS. NEaREST
COMPENSATION INSURANCE SiZE OF LOT p.� NOV!ON lOT � CROSS$T. �`�
(Thls saclion need no1 be compleled if Ihe permit is for one �^� 3 ASSESSC4
hu�dred dollcrs(5100)or less.) TRAGT /S I BLOCK lOT N0. 7•AP P,OOK PAGE PARCFL
�E�' USE ZONE �+P
I certify tha�in�he perlormonce of ihe work fo�which�his OwNER n � NO. �,�p_ J�,3— .3(l�j
permit is issued,I sholl nol employ any p son in ony manner S ��.`� �.� CON�TiOr:S �
ADDRF55
so as�o hecomr.subject io ihe Worker mpens �ion l •s. 'p U
CITY 1��]'� ZIP /��(O �
�Dafe Applicar a
NOTIC TO APPLICANT: Ii, a(1Pr moking his Ce/tifito'e af AR[HITE T R '`� T«� � � DISTRICT GRpUP TYPE FIRE �n'OCESSED BY O
ENGIVEER GYU NO. �J !JST. ZONE F�
Exemption, y�u should become subje lo �he Workeri V
Compensa�ian provfsions oi�hc labor Code,you must forih- pppofSS T d��"���� /J ' W
wilh [omply with such provisions or this permil shall be TEL. STATISTIUL ClASS:FICATION ' APT. CONDO. �
deemed revoked. CCNT�ACTO¢ E� NO. ���
LICENSED CONTRACTORS DECIARATION ClASS NO._L`=Dv.TIL UNITS z
UC.
I hereby aff�rm�ha�I am liceneed under pro��s�ons of Chopter 9 aDDrtE55` � NO. $EN'ER�dAP
(commencing wi�h Seclion 7000)of Dirision 3 of ihe B��siness and �i�.
Prefessions Code,and my license is in tull farce and ef(rc�. CiTr ttA55 gK � VALIDATION
50.FT. NO.OF NO.OF CNECK
LiCe�sa Number LiC.CIo55 SIZE �, STOR7E5 FAM'lIFS ONE
VALUAiION
Conlrot�or Dnl� DFSCRIPTION OF WO4K A D S I� ��
�I om exempt under Se[. �) ALTER � ,
B.BP.C.for/F1is rea5on �(/ �. REPA:R � f �� ��.2 li
USE OF /��� DEMOL
Dotc: ExiSTiNG BLDG. �/ � M• • • • • �
9 APPLICANT TEL. ' //�/�� I • � � �.7 J
Si nature FINAL
OY/NER�BUILDER DECLARATION (F4iNT1 h0. DATE Z ,L�"Q�'
I heie6y a(lirm�hat I am exempt From ihe Comractar's Litense J—
low for the following reason�Sectian 7031.5,B�s�ness and aDCRE55 FINAL � � � � �. � u
�iessions Code): tii 6Y r_ �
euito�N� a?_�`F3 7
I, os owner of ihe properly, or my employees wilh ADCRE55 �
wo;es es�he�r.c!e cc�p^.^.•^_!�cn.w�ll do ihe werk end i�q�irv ' .. •
the struc�urr.is not in�ended or oNr.red(or solr.(Saction � ,'
7044,Business and Professions Code). �rOvinlG TEI.
� I,as owner of Ihe property,am eaclusively conlracting CCN7RACT04 NO. � �
with litensed conlractors to tons�rucl 1he projecl(Set- qDCRE55
tion 70<A,Bufinets and Pralessions Code�. . � � •
CONSTRUCTION IENDING AGENCY SE�BaCK YARD HwY i�rApRO.?iihEF� �� wi�iti , . � . � .. ,
I hereby a(firm thet thcrc is a tonsiruction Icnding agency for f RON1 � ` '
the per(ormonce oi Ihe work ior which this permit is issued v.�.
(Sec.3097,Ci�.C.). Si�E
P.L.
Lender's Name
` lD!M Ref.N
Lender�Addrees P.C.Fee S Pe�m�r Fen (7/'�� ,
I cerrtfy ihot I ho�e reod rhis opplicarion ond slate that the i,s�a��e►�� ��•��� LD.MA P/C M
obova inlormotien is correct.I agree�o comply wiih oll Counfy Inves��ga�ion Fee ,S
ordinonces and Slate laws relaring ro build�ng consnucr�on, To+al Fee // /� 7" LDMA Pe�m.�
and ha• y a�thorize rapresenlalives of this County�o emer�
u o . above•me ned pro rty for inspection purposas.
SEF RFVEKE FOR F%PLANATOiY IANGUAGF
S�g� .e o� ppLcon�or Agem �e •
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