HomeMy WebLinkAbout1578A WORKERS'COMPENSATION DECLARATION /"�
� I he�eby offirm thot I have a certifica�e of consenr to self APPLICATION FOR BUILDING PERMIT �j
insv,�,or o certificote of Wo�kers'Compensation Insuronce,
�or o ceiti� copy thereof(Sec.3806,Lab.C.)
Policy No�Company l� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certctied copy is hereby furnished.. FOR APPLICANT TO FILL IN BUILDING q
ADDRESS �l U O L d
Cer�i ed copy is filed h the co n1y bui ding' pec- BUILDING,
tion epo�mant. DDRE55
DO�e Appli ont CITY ZIV I tOCALI7Y •
RTIF T F EXEMPTIO O WORK 5' SIZE OF tOi NOW ONLLOT CROSSSST.
COMPENSATION UR CE �
(ihis sac�ion need no�be com e�ed ii�he m�r is for o�e TRACT tocK ior iuo. ��R
hu�dred dollars�5100)or less.) �P�� PAGE PAR L
i� USE ZONE 1�
I[ertiiy ihat in the performnnce of the work for which�his ��R �� �
permit is Issued,1 sholl not employ any person in ony mahner qDORE Q� � �—I �'�ITIONS �
so as�o became subjea to fhe Workers'Compensafion lows. Q
U
�ate Appliccnt CITY ZIP �
NOTICE TO APPLICANT: If, after making thiz Certificale of ARCHITEC7 OR ��� DISTRICf GROUP NPE FIRE RiOCE55E�BY O
Eaemptioe, you ahould become sobject ro Ihe Workers' ENGINEER NO. ��T_ Zp� U
Compa�sation provisions of tha Labar Code,you must forth- ADDRE55 � '� � � �'" n^3 �'�(,J�
wiih compty with auch qovisiona or this permit aholl be
����' STATISiIGAt QASSIFICA710N APT. CONDO. fA
dsemad�e�oka�. CpNTRACTOR N(kJ Z
LICENSED CONTRACTORS DECLARATION ❑ . CIASS NO. DWEtL.UNITS_ �
1 hereby affirm that I am licansed under provisions of Chapte�9 ADDRE �Q �
(commencing with Section 7000}of Division 3 uf tha Busineas aid ��C. SEWER AAAP
Profauions Code,and my licenx Is in ful!farca oad eRect Ci�Y J - -- CLn55 - � � VALipAiION
^�� SO.F7. NO.OF NO.OF CNE K
liteese Numbar�!�_Lit.Class SIZE STORIES FAMIlIES ONE
�,� n VAtUAT1pN
C❑onitatlOr �at� DE RIPf��OF WOR� ���� � : '7/y�/� �
/X C?f!l
I am Yxompt undor Sec.
//�/ / MTER I
6.BP.C.for ihi�r�oson �— ZXI�� �" REPAIR ❑ f �
Date: EX ST NG BLDG. /� DEAAOI ❑ '.�
Siqnolurs APPLICANT J � TEL. FINAL <� �i
OWNER-BUILDER DEUARATION PR�NT ppT� 5 7.r�A ,
I horoby affirm thpt I am eaemp�from tha Contrpclor':Llcensa �r � � � i
Law fo�the followinp reow�(Soa�ioe 7031.5,Bu�in�u aed ADDRE �7`. � � � Fll�iq �a • � i
v.��io�.code�: W I • •3 6 7 5 �
❑ BUILDING _ I
1, as ownar of tha property, or my employsa�with qppRE5�5
wages a�rheir so�e eompeneatien,wtl�de the werk ond � • P • ' � �'`,� ��
ths itructure is no�imended o�oHered for aale(Secilon ��"��T� � 0� � ;?—�j I �
704t,Buainess and Profeuione Coda). MOVING TEL. �
� I,ns owner of the property,am sxelusivaly contraeting CONiRnCTOR ni0.
wirh lieansed eon�roe�on ro constr�ct�he pojact(Sec- qoouess I
tion 70N,Businau and Professiont Code}. �
CONSTRUCTIIXJLENDINGAGENCY SET�gp�K YARD HWY Apppp,��ryE WIDTt1 �
I hereby affirm that lhere ia a construction lending agancy for FROM i
�ho porfwmonc�of fh�work fw which this permit ia iesued P.L. � i
(Set.3097,Civ.C.j. SIDE
v.i. I
Lender'a Name �
L�MA Ref.N
m Lender's Addrex P.C.Fee S Permit Fae .�^�� �
� I cartify tho�I have reod Ihis applimtion and state tha�the hauance Fee �e.� v LDAAA P�C N
above information is cmrocl.I ree to comply with all Counry ����uiyation Fea
$ ordi tes State laws re ting fa building conatrucfion, Toal Fae LDMp Perm.M
a hereby au horize r ras tativas of this Covnty to enfer
'� u on tha obo - n�i ed operry for i��ction pur f�s.
� . � see nevuu ra exnnrumar uewuwce
pnon,r nppliq o,Aq.n� oo�
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