HomeMy WebLinkAbout1025A WQRKER$'CO':.PENSATIO'J DECLARATION
� �o�,bY o:;;�m rha�I have a cer��F�ca�e aF�o�,e�,�0 3��� APPLICATION FOR BUILDING PERMIT
insi,c,�or a certificate of Wo�kers'Compensation Insurante,
or o ce.�iiiied cop �tie;eof lSec.�900,Lab.C.) COl1NTY OF LOS ANGELES BUILDING AND SAFETY
�r 5 .L � S �
Polic No. Compony
Cerrlied cepy is hereby f ishe . FOR APPLICANT TO Flll IN 9URD�NG •(L
ADDR_SS �za g 6 f G'�,�
Ceni(icd tepy is filed rh�he � y bui �ng nspec- BU!�DinG �� `
IiO�de O��men � ACDRESS �
y ♦ �I
Dalc��_/����PPlicont CITV 1� ZIP LOG1LItv l
IO�(�? �ERTIFIC�E OF EXEM.PTIO FROM VJdRKERS' NO.OF BlOGS. niEARESi ,fi
OMi'ENSATION.NSURANCE SiZE OF LOT NOVJ CY LOT CRO55$T /' /,�rl�� '~ f ��
(This section need not be com,Ipled if Ihe permil is for one ASSESSC ,
hvndred dollors(SI00)or less. TRAci CIOCK LOT NO. �TAP BOOK PAGE PARCEL
�1 IEL USE 2CYE MAP
I cert�fy�hof�n ihe perlo�mar+ce oF the work fo�which ih�s C'NN�R �1� ' NO � No.
pr.�mi�is issued,I sholl not e.mploy any person in any monner S�FCint a
7o as lo beCame sVbjecllo Ihe V/Crkers'Compensafion lawi. ADD�E55 J/ CONDITIOVS �
U
Do�e Appliconr LITY 21P �
NOTICE TO APPIICANT: If, ofier moking�his Ceriifico�e o( ARCHiTECT Oe TEL. 0'S1RtCT G40ur 7YaE FiR: P40CESSED 9r O
Examp�ion, you sho�ld becoma s�blect to �he Workeri FNGI4EER NO. COhST. ZONE V
. Compensaiion orovisions of tha lobor Code,you must forth• ��,.g«5 �� �� �?����i I, ��c+.^O_ w
/ winc �omply with such provisions o� this permir shall be ��y �.�
deemed revoked. TEI.p�T . SiAT:STKA�Cu55iFiCnTiOv APi. CCNDO. (n
CONTRACTOR O.D�D Z
LICENSED CONTRACTCRS DECLARATION r �i� QA55 NO.�DV.TIL.L'NITS
I here6ya}firm tha�I am licensed under provisions of Chop�er9 A�DFE55 nlD.
(commenring w�!h Seu�on 7000)cf Di��s�en 3 e(�he 6�e�nese or+d LIC. ��'�"�NAP
Pro(essions Code,and my license is in full force and effect. Ciiv G . CtA55 P! � VALI�ATION
50.FT. NO. � NO.O� CHECK BK. PG.
license Number Lie.Closs� SRE STOR'ES FAMI�IES ONE
3 g n � �• hEw VALUATION
Contractor �� �� DESC4!PT!ON O�W04K I� ❑ s �!'�O�
' AD7 � �� ,
I am e■empr under Sec. �
ALTER
B.BP.C.far thie rsoson REPAI4 ❑ _
Da!e: USE OF ` CE'AOL
EXISTING BL�Co. I� ..(.�- ❑
$Ignoture AOPLICANT T:. FINA
OWNER-BUiIDER D'CtARAT10N �����i � � DATE
I hereby atfirm�hal I am ezempr irom�he Conrroc!or's ticanse •
Law for Ihe following reason(Sectlon 7091.5, Bu�ineee and ACC4E55 ' � Ott - fv—' HNA "
Pro!e�slons Ccda)� Sy L�
❑ BU:IDIN^v
I, a�owner of�he prFerty, er my employeef wiiti A�:4E55 / ' �jr..Q� ���
1 wc es os thcir solo com ensa'ion,will do iha wcrk and �«A��TY � /b
the s!ructure I�no�in!ended or offe�ed for sale(Secllon
I 70/4,Business ard Prafessions Cade�. �1Cv:4G TEI.
� I,as owner of the preperty,am e.clusively contracting CCNTRACTCR NO. /C� /nC r ' �
with Iicensed eonr.acten�o cons�ruct rhe praject(Sec• �� � �'� '�� O Z J ii
lion 70<e,Businese and Frofeseions Code. AD�CESS
' RCCUiRED ICTAL SEi9ACK . I��. C���J j: • • • • o �
CONSTRUCiION LENDING AGENCY cET gq�K YARD HWV PROD.LI!.E WIDTH
I hereby affirm ihat lhere is a tonstruc�ion lending agency for frtCrvi � � ���J��
Ihe per(ormance of ihr.work for which this permil if is�ued D l
(Sr,e.3097,Civ.C.). sioE • e .?j::(:T
P.L.
Lender's Nomo lD!.'A Ref.M 0 E3 1 9—t3 II
: P.C.F�e S �e.m�i Fee �_, ��
• Lender's Address
g I cenify thet I hava read ihis application and staie that the ieeuo�ce Fee �4 C�� �D!.1A viC�
; abovo info�maiion is correcr.I ogree�o comply wl�h otl Coun�y �nres��poi�on Fce /�
ordinan es nnd Stale laws reloting 1 building construc�ion, Tc�al Fee � C () LD4,A Pe�m.M
oncf hcreb aulhorizc re ntative oi Ihis County lo entcr
pon�he .69ve-men' ne - �opr.rty r inspeclion p rposes.
, / � �� fEE REVERSE FOR FX�LANATORY LANGUAGE
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