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HomeMy WebLinkAbout1529A (8) 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 � I y�r=m� � y - �;���—� y . _� � � � a = o� " �y�,m06 Cyd>-�_ C h'6 �� � GQ: in � C Y . f• O O p �u� G 2� O� O r' a� 4 V � � ! . 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