HomeMy WebLinkAbout1049A (5) �YORKERS'CO.MPENSATION DEClARA710N �
Insurebo�afcerlif�a'�eo�Wokers''Cem1pensolionslnsuranter APPLICATION FOR BUILDING PERn►.. _
o�a cenified copy ihe�eoi�Sr.c.3800,1a6.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY
Policy No. Compony ,j
� Ce�tHied copy is herrby iwnished. FOR APPLICANT TO FILL IN AV�IDiN^v 09 �1/ �ipD�EC�iQs Q
AD�JRE55
� Ccrlificd cepy is filed wilh Ihe co�nly building inspec- BUIIDtNG �D
tion depar�ment. , ADDRESS
Dale Applican� GiTY 21P LOCALITY I�'�1A`.� 2
CERTIFICAIE OF E%EMPTION FROM WORKERS' NO.CF eLOGS. NEAREST SU�SEr' CJPOyS//',�
COMPENSATION INSURANCE SiZE OF LpT NOW CN LOT CRCSS 5T.
(This sec��on need no�6e complefed if�he permil le fo�o�e ASSESSC4
hundred d011ars(5100)or less.) TRACT BLOCK lOT NO. IfA7 BOOK GAGf PARCEL
OWNFR\ /�WC n0 7� USE 2C':E MAP
I ceriify ihot in the performance of�he work for which�his h0. 2� � ),;
permif is lesued,I sholl not employ o par�on in any monner � SPECiAt p„
so as lo betome s�bject 10 ihe 1No� i ompe lion lows. A��RE55 '/ CC'J�ITIONS �
�0f7 Citr /� LP V
Dale ��� Applic �
NOTICE TO APPIICANT: If ofler ma4ing ihi7 Certifi a19 of A4CHI7ECT OR TE�. D'STR�CT GQOUP ivCE F�4E FROCt55Eo BY O
ENG�NEER NO. CO\' 20^:E h
Eremp�ian, you sheuld eco eublecl to the Workers' rt V
Cor..persa'ien prcvisicr.s E�. Lc6or Cede,Y^u mu!1!Cr!h' ADD�c55 �V �� W
winc �omply wilh s�ch p ision7 or rhis permit shall be .
deemefJ fevo4ed. TE�� �[ �/ STATISTICAL CLPS IFICATION APi. CON . N
CO'�TRACTOR NO.J � fXJ� Z
LICENSED CONTRACTORS DECLARATION ii�, � CLASS NO. DWEIL.UNITS
I hereby effirm ihai I am licensed unde�provisions oi Chopter 9 AD7ttES5 � C' n0
(commencing wiih Sec!ion 7000)of Divislon 3 of:Fa Business end ���. ^ �Y��R�P
Professions Code,ond my license is in full force ond effect. CiTv /(J A GLASS G.' eK �, VALIDATION
_a+)ba rf�L�' �, C 3� 54.FT. O.O� NO.OF CHECK
License Number �b.�..]�_liC.CIo55 S�ZE STCRIES FAMILIES ONE
] '/ VALUATION
COnIrOCtOr,,/ON�V. ,�.�Q�SUXDa1n. CESCR'PTICNO�wO4K T n N� ❑ s�,O4'
❑ N ��il ADD ❑ ,
I am e•empt unde�Sec. �
AITER
6.8P.C.far this reason / ' �pp�q S
� USE CF � :� O(-S�'i
Da e; EXISTING 2LIX"i. CEMOL
S�g�oture A?PLICANT TFi. FINAL �=• • • • ' �
01bnFR-BUIID'.R DECLARATION IPRiNi� NO. DATE J'� �
I hereby affirm ihot 1 am e.empt Trom�ha Coniroctar's License � • •�l 9.C J
low ior Ihe following rnason(Section 7031.5,Business and ADCeE55 FINAL F �
/�ssions Ccde): : r: 8Y � .. .l:�.^;�
BU:LC!":G
I, cs ownrr af�he propeny, cr my emplayces with ADDRESS ��C:i—ii J
wagPs as the.ir solr.campensaiian,will do�he work and ��A�iT� ,
�he s!ruciure is no7 intended or offered for sale(Section
70d4,Business and Professions Code�. �:OviNG TEI.
� I,as owner o(ihe prepr.rty,am e.clusively connoc�ing CCNirtaCTOa NO.
wilh Iicenled coniraclors to con5truct ihe prolecl(SCP ADD4FS$
�ion 7044,Business and Professions Code).
CONSTRUCiION LENDINGAGENCY SE7 BaCK �/4D HwY �U�AFRC?iinE� V•� YlIDiFi
I hereby affirm tha�there is a consiruc��on lend�ng a9ency for FRCNr
�hn performance oi thr,work fo�wh�ch�his perm�t is issued a L.
(Sec.3097,Civ.C.). S:DE
P.L.
Lender's Name
LD!lA Ref.N
lender's Address P.C.Fes S Permi�Fee ,
I cerf�fy thal I hove rnad lhis applicotion and s�ale 1ho1 the ISfYOnCq FP.q 1�. Q LD�.W PiC M
e6ove iniormaiion is correct.I agre.e lo comply with all Counly I�ves•�ga��on Fee .
ordinances and Slate laws reloting 10 building consiruction, Ta�ol Fee � L�MA Perm.M
ond her by aulhorire represe.niaiives this Counly lo enler
, �pon ..ob -menti ed properly r inspectian p�rposes.
i
9'?3� SEE REVF�SE FOR FXPLANATORY LAHGUAGE
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