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!
T✓F� IYdLB�
Sipnmura of ppplicum or Agen� ppy I
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