HomeMy WebLinkAbout1629A t WORKERS'COMPENSATION DECLARh710N ��
fIW.B�f+hffirm thot I have o cerlifimte of�o�5e�,fo 5a,f �� qpp�,�CAT10N FOR BUILDING PERMIT
inaure,or a certificate of Workers'Compensation Inauronca,
or o cerfifiad copy iherBGf(SgC�3800,La6.C.)
Po❑licy No- �� Company
COUNTY OF tOS ANGELES BUILDING AND SAPEFY
Cartified wpy is hereby furnished. FOR APPLICANT TO flLl IN BUILDING
ADDRESS p�'
� Certified tapy is filed wifh fhe county building inspec- BUILDING /J
lion dapattment. ADDRE � ��q��
NEAREST
.Dole Applicant CI ZIP � CRO55 5T. �/
CERTIFICATE OF E%EMPTION fROM WpRKERS' rv0.oP BLOGs. assEssoR
COMPENSATION INSU&AMCE .. . SiZE O��aT NOW ON LOT MAP BOOK PAGE PARCEL
(This aeclion need not be completed if the permif is for one USE ZONE MAP
hundred dollon(j10p)or lass.) iRAR BLOCK LOT NO. il/ NO. ���
TEL �
OWNE /^ ��7 7 �` SPECI -�
1 cartify that in the performance of ehe work for which ihis � - ti [ONDITIDNS
� permif is iswed.I cbpfl nof 6mpl any person i any mannar ADDRESS � ��'� �� CONST._ ZONE P�ESSED BY � u
so as fo 6ecoma w6ject lalhe o i Com ipn laws, KY.,_ � �
r
CITY d'/77�, ZIP
��'e � ^ P'��� ARCHITECT OR TE�. STATISTICAt CtA551FIG4TlOh1 ppf, Cprypp, �
NOTICE TO AV LIG4NT: If, a er mokinq this Cer imfe of ENGINEER rio.
Examption, you should bec e subject fo the Workeri ., �P.55 NO. �� DwEll.UNI75_ a
Compansotion provisions of the Labor Code,you m�st forth- qpDRE55 SEWER MAP V+
with compiy wilh suth proviaions w fhis permit shpll be Z
deemed revoked. TE�. -
COMRACfOR pp, 8K. PG, VALIDATION
LICENSED CANTRACTORS DECLARATION ���
I hereby affirm that I am licensed under provisions of CFapter V qD�RE55 r10. VAIU/�IOH ..
(commencirg with Section 700�)of Diviaion 3 of the Business and � C� s Q ��
Professions Coda,and my license is in full force and effect. Cirv 0
SQ.Ff. 6/� NO.OF NO.OF CHECI(
Licanse Numbe� Lic C�ass SIZE �01p STORIES FAMILIES ONE
Ca�lratlor Date
DESCR�PTION OF WORK �w � $ �1 6 2 9 A
/� �• • • • • �
I am exemp�under Sec. p�hR � FINAL ' ^,� : �- .
B.&P.C.for ihis reawn �4 REPAIR � DATF�� �!_�� '' - � • �7 4.2 5
Dole: U�� FIN/1L ' • • •�CF,�j�
EXISTMG BLDG. �FMOL ❑ 8y \�_�.��
Sipnnfute - APPLICANT NO. �OO/ —�—•. 0 Z 2 4—8 5
OWNER-BUILDER DECIARATION PRiNi
I haroby affirm�hat I am eaempt from the Contraclor's License �
law for ihe following reaaon(Sedian 7031.5,Business and A�DRE � !Qs' / �^ q�'
Professions Code): pR
.I� 1, ps owner of ihe propeAy, or my employees with ��DING � �Q�
woges as their wb compensatio�,will da the work and
the strucfure is not iMended or offered for sule(Secrion I la/d�TY
7Wd.Busineas and Professions Code). MOVING 7E1.
Q1,as owner of Iha property,am axclusively taniracting ' NTRP'ROR NO.
with IiCensed confractors fo construcf fhe projact(Sec- pppRE55
tion 7044,8usiness and Profeuions Coda). , .
REQUIRED 10TAL SET&4CK FROM E%15T.
CONSTRUCTION LEN�ING AGENCY SET BAGK YARD HWY p�p ��N WIDTH ,
I hareby affirm ihal there is a construction lending agenty for � FROM "
fhe performpnte of ihe work fo�which this permit ia issued p,�, �
(Sec.3097.Civ.C.). SIDE .. .
P.L
Lender's Name
$ � P.C.Fee t Vermit fee ��•�J� .
lender's Address '
� I cer�ify that 1 have read this opplication and atate that the �U-,S�
Iss�ance Fae
$ obove informotion is carect.1 agree to mmply with oll Couny � �mm�gotio�Fee �j�,�� I
ordinancas and Staea lawa relating�o building construcllon, io+al Fee �
� rC(�r�eby a ize represenfalives of this Counfy to enter
� pn the a ve entio d prope for inapeetioe purposes.�� �
� 7� SEE MEYfRSf FOR EXPIANATpiry LANGUAGi
Signo�urs of App eone or Apent pa� I
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