HomeMy WebLinkAbout0794A (4) l"JORKERS'COMPENSATION DECIARATION •j�
ins�rebora(celif[o,�eofVJorkes''Compe�sa�'onslnsu�anceF APPLICATION� FOR��BUILDING PERMIT ��
o�o certified topy thereof�Sec.3900,Lcb.C.) �
COUNTY OF LOS ANGELES . BUILDING AND SAFE7Y
P❑olicyNo. Company
Cerrified copy is hereby furnishr.d. FOR APPLICANT TO FILL IN ncovess L�C��=� � �%/ "�e�r;'>
� Cr.rtified copy is filed wi�h the coumy build�ng inspec- BUiIDihG �ii� � � �7 i `� QQ
fion depaHment. ADCRE55 i-t�_J:� �i /L/�� �� ,� l� IOGAtIiY� Q� r ) f�7/��
Dale Applicant CITY /J�f��7./'1 J n 21P ' �'� CROSS 5T.Y / � -+l��� �
CERTIFICATE OF EXEP:.PTION FROM WORKERS' NO.OF BtDGS. n5SE55CR
COMPENSATION INSURANCE 5�2E OF lOT NOW ON!OT MAP(ipCK PAGE PARCEL
This section need no�be com I�ted if the ermit is for one J �h u5e zChE nenr
hundred dollors(SI00)o�less.� P rRACT�—� '� BLocK LOT NO. � NO.
TEL 5F[CIAL
I c�rlify ihat in�hr,per(ormonce of�he work for which this �'f�FR �� � �,(L� NO��� '/�7 CCh�iliONS �
'i!- \ �f Di51RiC1 GROUP IYPE FIRE PROCESSED'i �
permi�is iss�ed,I shall no�employ,ony pr.rson in any mannrr , ��n i ^ I I ` ,� �„i
AD7RE55'Zi�i� ,F-!: �I�J `'�C�:�C � fCNS..
so as to bn ome subjr.ct�o the Workera'C mpensarion Lows. `7 � � ti r;
��] � / , �� �, .. V �s
Daie � • • �nppl�cnr6��l��/��� cirv LfP %' Z�� �� srnusncnian s�ricanoN AFT. CUN �
NOTICE/TO A PLICANT: If, of4/makin�thfs Certilicafe of ARCMITfCTCR �E�. ____ �)
ENGIhFFR h0. CLA55 NO. D':JELL.UNIT$_ �'-�
E+emption, you should become su6ject to the Workcrs' «
Compensation provisions oi the labor Code,yo�m�st forth• ADCRESS 5EY�fR fnP.N '-ni
wi�h tomply wiih such orovisions or this pormit shall 6e TEi .�
deemed revo4ed. CONTanCtOR NO. BK. PG, VAIIDATION
LICENSED CONTRACTORS OECIARATION uC, '
I h?reby c!firm:hat I am licensed under provisions af Chop�er 9 npCRE55 NO. VALUATION
(commencing wilh Secrion 7000�of Division 3 of ihe 8usiness and ���, ' O O O «7
Profr.ssions Code,and my license is in futl lorce and effect. CiTY [LASS S ,
50.FT. ti0.GF NO.CF CHECK
License Number Lic CI055 SIZE STCRIES FAMJlIES CN'
DESCRIPTIO^1 OF\VOPK 7 I N`W � S �
Conimctor Daie �
ADO
�I am ezempt under Sec. �
AITFR � FINAL
B.BP.C.for Ihis reoson ' � RfvaiR � DATE
Dafe: u5E OF FINAL....
FXISTING BLDG. �= � �`:•.OL ❑ g �
$i�nOfuiO
APPLICANT iEL. r I
OVdNER-BIIIIDER DECIARATION �FR!Nf NO. •
1 Mereby aFfirm�ho�I om e�emp�f�om the Conrractor's Licr.nee
Law for�he following reason(Section 7031.5,Business ond /DCQE55 � '
�079.4A
Pro�essions Cadn): Fk; ti
. OBl1RDING . �I� • • • � � .
I, as owner of Ihn preperty, or my e.mployees wilh qooa[55
wages as the.ir solc compr.nsa�ion,will do�he work and �p�t�TY � � • •,j�rj Q
Ihe s!rutfure is not intended or o(fered for sale(Section
7044,8vsiness and Prc�ess�ons Code�. MOVMG TFI. � ,
� I,ae owne�of the property,om e:clusivr.ly controcling f vTRaCfOe NO. • ^ ;;��,j��; _
with licensed cont�ac7ors�o conslruct Ihe project(Sec- qDDRE55 � ?�Q'�3
�ion 7044,Bueiness and Professions Code). '
PCCU!4F0 TOTAL SEI9ACK F4U•A E%ISf.
�ONSTRUCTION IENDMG AGENCY SEi CACK vnao Fivn FRO�.IM� wiorH � '
I hereby affirm�ha�there is a consfr�uion lending ogency for FRONi � � �
tha periormance of ihe work for which this permit is issued a.t.
tSec.3097,Civ.C.�. SiD:
P.L.
Lendei s Name ^ �r
� o
Lender's Address P.C.Fee 3 Permn F•r. L 'l
I certi(y tha�I havrt reod rhis applico�ion ond sta7e thot fhe. Iss�ance FPe 1
� �J �n
above informalion is torrett.I ot�rr,e fo comply wiih all Counly in.nr�goi�on Fee `�= 1'
ordinonces a�d Sta�e laws reloiing to building conshutrlan, To�al Fce —
�..and hereby authvrira represen�atives of Ihis Counly b eMer I�
upon tha obov;meniioned�property for inspeclion rpos s. �
��,,r����L��l�� �3O� SEE REVERSE FOR EXPLANATORY UNGUAGE , �� 1�
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