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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� ( •_ � - _ n -- .. �. � ,� � .. ,� � � � u: :�-. 4 7. 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