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HomeMy WebLinkAbout1022A WORKERS COMPENSATION DECIARATION ��SY' � ` ' � 1 hereby o�;.m that I have o ceriifica�e of consent to self APPLICATIfJIV`.F�R BUILDING PERMIT � insure,or a certifimte of Workers'Compensation Insuronce,; . ' ���ified wpy�hereaf(Sec.3800,Lab.C.� +_ COUNTY OF LOS ANGELES BUIL�ING AND SAFETY ��f7�/ � �J Policy No. Compony �f^���vctt.` r � Certified copy is hercby furnished. FOR APPLICANT TO FILL IN BUILDING ��y y S_ ���� � ADDRESS Ce�tified topy is filed with Ihe couniy building inspec- BUiIDING �/�d iondeportment. AODRE55 �T7 Qv �.✓ Date Applicant CITY, L � ZIP IOCAIITY � CERTIFICATE Of EXEMVTION fROM WORKERS' NO.OF BLpGS. �qp�,5i SIZE OF LOT NOW ON LOT P�,d�LPc�+-c� COMPENSATION INSURANCE �/ [ROSS ST. �y�ct[.S ' CG4,�c,a,� �Thia aeeliOn need nof ba completed if fhe permit is for one TRACT ���Q ASSESSOR hundwd dcllori(s100)or leu.) BIOCK LOTNO. - MqPBOOK-- -- VAGE PARCEL ��R//�` QN A_. TEL. / USEZONF � � � � 1 cartify rhat In the performance of�he work for which this w� L/�� NO. 37i'�1b parmit is iuued,1 aholl nof emplay ony parspn In ony mCnner qpDRE55� N(.i}� ���� O eo as lo bscom�sub�ect to tha Workers'Compenwf{on Low7. CONGITIOMS C�TY �«Q� ZIP 926s�-7'��a U. Dote Appllmnt ARCHITECfO TELy �� NOTICE TO/WPLICANT: If, aher moklny�thie Ce,tificple of DISTRICT GRpUP TYPE FIRE o8v O Exom tion, o� should 6�com�-sub' ct �o �he Worke�e' ENGINEER �fd1 �4H� P Y W /� y�NO. A�r WNST. ZONE � I'� Campensallon provlaiona of�h�labor Cod�,you muW forrh- nDDRE55 �C � v��/7�E�(�E 2 /�� � f�/ U wllh comply wllh wch proviaiuna cr this parm{t sFwll b� W� -f- w a ��r�Y��. . .. CONTRAROR ! �L 4 T�. STATISiICAI ClASSIFIGTION qp�. �pNpp. � IICENSED CONTRACTORS DECtARATION ��C. aAss r�o. '�� DWEu.uNirs d � I har�by affirm fhof 1 am Nwnytld vndo provisiona of Chapter 9 ADORE55 NO. (eommancirg with Sec�ion 7000)of Divi�ton 3 of ths Bwinass ord �K SEWEp nAp,p Rofemion�Cods,and my licanw la in full forca and effsct. CITY... - [u55' VALIDATIQN SQ.FT. NO.OF NO.OF CNECK BK. PG. Liconse Number Lic.Class SIZE STORIES F ILIES ONE w� T Eiv�C v�+w�no� Conrraeror Dare DESCRIPTIONOF K p w S �/�� ADD ❑ �7 � �I om eaampt ur�der Soe. ��R � B.dP.C.for thia reason RFAAIR � f I Dora: use oF EXISTING BL�G. DFMOI ❑ Siqnorure AOFI�GNT TEL. � � PRINT pp, FII'fAL OWNER-BUILDER DECLARATION DATE �s,� �1 0 2 2 A 1 hereby offirm�ha�I om examp�f�om fha Conkuctor'a License Law for ths foflowing recson(Secllon 7031.5,Business and aoDRE55 F�� �• • . . •� Aoteuloni Code�:- � BUILDING gy I • •4 9,2 5 1, as owner of the property, or my employeas with ADORE55 wogas as iheir wle compennation,will do tha work and • • •4 4,,�5�i Ihe itructure ia ne�intended or offerad for wia(Section ����TY 7014,8usinex and Proteasions CodeJ. MOwNG TE�. �Q 0&-g� � 1,os owner of tha property,am exclusively contracting CONTRACTOR NO. with licensed controCtOrs to construct the projact(Sec- ADDRE55 tion 7044,6�siness and Professions Coda). CONSTRUCTION LENDING AGENCY SET gqCK YARD HWY TOT'°'�SEt PROP.LME WIDTM I hereby affirm that there is a constroction lending agency for FRONi �he performance of�he wo�k for which Ihia permit is issued p,�, (Sec.3097.Civ.C.). SIDE P.l. Lender's Nome . 3��,!' LDAAP.Ref.M Le�der's Addre5l P.C.Fee S Permir Fee ' � I certify fhot 1 have read thia application ond state that the /O� luuance Fee lDA/J4 P/C M ? above informotion is correct.I agree to comply with oll CouMy Investipotion F t � ordinances and State laws ralming to building construdian, io�al Fa. & and hereby outhorize represento�lves of Ihis County to anter y g �MA ierm.M � up��oJn Ihs o6ove-mentionad"�properry for Inspection purposee. Y /J_��` �r __� /O�Z �Q� SE!YEVfYSE FOR EXPWiAiORY LANGUAG! 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