HomeMy WebLinkAbout1529A IWORKERS'COMPENSATION DECIARATION '
I here6y affirm�hat I have a certifimte of consent to��f APPLICATION FO ,�� ; � re■ f����� �
insure,or a certifimte of Workers'Compe.n.sation Insurance, - � � ,fl
or a certified wpy thergyYf{Sec.3800, b.C. COUNTY OF LOS ANGElES �OICDI����ETY � 1�
PolicyNo. � ��f COmpany
BtIItDING � D �j
❑ Cerefied copy is hereby furnished. FOR APPUCANT TO FILL IN ADDRE55 �' L
� Certified copy is fifed wtth the co�My building inspeo- ��� �� 3 ti�
� \ iion departmeM. � q �]
DOfB�Applicont Cltt � ZIP / / IOCALITY
NO.OF BLDGS. NEAREST
CERiIFICA7F OF EX N FROM WORKEk SIZE OF LOT NDW ON LOT CRO55 ST.
-COMPEN ih}SURANCE- - - - ASSESSOR
(This section need not b mpleted if tha permit is fat ona TRACT BLOCK LOT NO. hW,p gppK pAGE PARCEL
F�ndred dollars($100)or leu.) �/�"ji� TE�' r u5E 20NE MnP �
OWNER �. r b
I cartify ihat i�the parfwmance of tha work for which rhis ��
permit is isiued,1 8hall not employ any n in cny manner ADDRESS SPEC1Al }�
.. CONDITIONS
so as to be me subject to the Work _ Compensation laws. � O
atv zir
DateC�.4PPli[ ARCHIIECf OR TEI. DISTRICT GROUP TYPE FIRE PROCESSEO BY �
NOiI TO AVPIICANT: I a r making this Certifi te of ENGINEER nro. 2 Con�s E �
Exemption, you shoul ome subjetl to the Workers' 7
Compensalion provisio s the labo�Code,yo�mvsi fonh- ��R� 2' �J C a
with comply wifh w provisio�s a thia permit ahdi ba f �� ��� ��'7 STATISTICAL CtPS51FICA710N qPi. [onrpo. Z
deemed revoked. coNraacroe No. _
IICEniSED CONTRACTpRS pECIARATK3N _ � y� cu.ss No.�,_oweu.uwrs
I hereby affirm that I am licansed under provisions of Chapter 9 ADDRE55 «� . . $EWER MAP
(commancinq with$ection 7000)of Division 3 of tha Business "�y ���� -
CITV d�-v✓�1. CtASS
and Profesaions Coda,and my licence is in futl force a effect. gK. p� YAIIDATION
SQ.tT. NO.OF NO.OF CHECK
License Number_��Ei[.Class SIZE d S70RIE5 FAMIl1E5 ONE
/�� vnwanoN /
Contractw •-++�•f ppfg_� �ESCRIPTION OF WORK a A� D s � �Q��
❑1 am exempt under Sec. ALTER ❑ � �1 5 2 9 A
6.8P.C.for ihis reason REPAIR❑ _ ��� � �.�j�
Dnle: FX STING BLDG. � DFMOI❑
5 narura ' J ••3�7�
APPUCANT 7EL �!,�C7
9 OWNER-BUIIDER DECLARATION (PRiNi� �'!� 61 nip_ W jOo- pA� � r�•3 6 7 5�
I he�eby affirm ibat I pm exempt from Ihe Caniroclor's license - qDDRE55 �� 1�,��(�� Q�.���`8 9
Low for ihe following reason(Sadion 7031.5,Business and FINAL u .y��,
Professions Code)_ -. � : � . ... . PReSENi By +,
❑ �, as owner of ihe ro e BUILDING
p p rty, or my employees with qpp Y, ,/���
wagesaslhairsolemmpenwfion,wi6dolheworkond �� � - - � - - �C �b•4L�f.(� Z- �.'
the structure is not�ntended or offered for wle(Section ����TY
' 7041,Business and Professions Code.) MOVING TEL � 5-��r�Cio ,p
❑ I,as owner of the property,om excl�sively contracling roMRACTOR NO. l�4y
with licensed coMracton ro consvuer tha projecr(Seo- - �
tion 76d4,Busineu and Professions Code.) A�DRE55
REQUIRED YA� H� AL SETBACiC FROM � � IST,
CONSTRUCTION LENDING AGENCY SET BnIX PROP.LINE wi iH
I here6y affirm fhat there is a construction lending agency ior FRONT
the performance of the work for whith this permit is issued P.l.
(Sec.3097,Civ.C.). �� SIDE
P.l.
Lende/s Name � IDMA Ref.N
� P.C.Fae F Permit Fee �
� Le�der's Address
� I certify that I have read this application and state thor the issuance Fee � LDMA P/C N
gabove informotion is correct.I agree to comply with all County Imee�igoiion Fea
� ordinances and Stata lavrs relating ro building eonstruetion, 7oroi Fee �� �DMA Pe.m A
Q and hereby authorize representatives of rhis Couny m enter
� upon ihe ove-mentioned prop y for inspection purposes.
SEE REVERSE FOR EXPLANATORY IANGUAGE
I^ Sigrwlure of Applic 1 or Agenr Oore
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