HomeMy WebLinkAbout1760A IWORKERS'COMPENSATION DECLARATION ��� ��
I hereby affirm that i have a certificate of tonsent to��t APPLICATiQN FO��ll�L[9�11VG PERMIT
insure,or a certifitate of Workers'Compensation Insurance, �
or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS t�'r E�p � �e; �,,��I {N(1�-/�1� �
Policy No. Cnmpan � A� `-" ���. '
Y . .
❑ Certified copy is here6y fwniahed. FOR APPLICANT TO FILL I ��_
❑ Csrtified copY.is filed wifh Ihe touny building imp�- �I���
� tion dapariment.. .. -. � A�DRESS I 3 � - �v,r',t ��/-
ZIP I��S
CITY � ��C/ IOCALIN
Date A�IicoiN P�p.OF slOGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE�OF Loi Now oN�07 / [RO55 Si.
COMPENSATION INSURANCE ��R
(This section need not be completed if the permif is for one TRAQ ��� eLOCK LOT No. µqP BOOIC PAGE PARCEL
h�ndrad dollars(;10p)or leu.) TE�
OWNER Q �Q �' /p�p � � 5�'�N�E MAP �
1 certify fhat in the perfwroWlca of fhe�ork for whicFi thia ;` ��L
parmit ia iuued.1 sM�all not employ any perw�in any ma�ner ADDFESS/33'.� (' �f[/iC'.� �iV• � �pNDITIONS O
so os to become subject to the Worken'Compenaation Laws.
. - cm � /y ziv /? v
Date Applicani � ARCHITER OR TE�� DIRRICT GRWP TYPE FIRE y �
NOTICE TO APPLICANT: If, aher making ihis Certificate of ENGINEER u/,I/C.T itd O. ,.,",�„� ZONE �
Exemption, you should become wbject to tha Wwkers'
Compensotion provisions Qf the Iabor Code,you must fw�h- ADDRE55 � �h� �' w
with Comply wifh Such provlsloni or this permii sholl be TE�� STATISTICAL GUSSIfICATION qPT, CONpp, �
deemed ravoked. � CONTRACTOR N0. Z
LICENSED CONTRACTORS DECLARATION t�C. MSS HO.�kVFll.UN�7S -..
I hereby affirm ihof 1 om licensed under proviaions of CFwpfar 9 ADDRE55 NO.
{commencing with Section 7000)of Division 3 of fha Business LIC. SEWER MAF I
and Profeasions Goda,and my license ia in iull fwce and eHect ��TY ��� BK. PG. VALIDATION '
50.FT. P�.OF NO.OF CHECK �
liwnse Num6er Lic.Closs SIZE STORIES FAMIUES ONE �I
YAIUATION �
Contrpctor pote �ESCRIPTION OF WORK N� s �G c a �n �
❑1 am exempf�nder Sea �aP /.d/+(/�! L!/.G C! ADD ❑ � , z}']Q p A� I
ALTER ❑ ;� •'�
6.8P.C.for ihis reawn / �� ' <<'vF REPAIR❑ s ••� •
°p�e` ExlsT�c stoc. oenna❑ I ••4 3 0 0
Signature ����'7i 7Et.
OWNER•BUILDER DKLARATION �(�IM} /PQ, /P.L}�.}/vo pp i/// �' FIN/LL • !�►U 3,O�O�
I hereby affirm that I am exempt from the Contratlor's Licensa . . �p� �Q,1 7—$9
Law for tha following reason(Section 7031.5,8usineas and ADORESS/��'�S /g-'CO �iV« L iv, F��
Professions Code�: . pp�N1 gy
� BUIL�ING
I, os owner of the property, or my employees with qpDRE55 � ��
wages aa their sole compensation,wil�do ihe work ond �
the srr�cture is not intended or offered for wle(Section ����n" .
,_,/7044,8usiness and Professions Code.} - MOVMG 7EL �C^�
�� I,as owner of the properfy,am exclusively conlracting ��R'4CTOR Np.
with licensed contrecfors to consiruct fhe projecf(Sec- pDDRE55 ^
tian 7044,Busineu and Professions Code.) n y�y �
CONSTRUCTION LENDING AGENCY REqUiRED YA� �, TOTnt SETBAQC FROM � EXISS. �(//`✓"" �
SET BACK R P ll E TH �
I hereby affirm ihot there is a consiruction lending agency for FRONT
the performance of the wwk for which this permit is issued v.l.
(Sec.3097.Civ.C.). SIDE �
P.L.
Lander's Name
� � LDMA Ref.N -
Lender's Addreu P.C.Fee f Permi�Fee �
° I certify that I have read this application and state ihat ihe Iss�ance F e V IDMA PiC N ►
� above information is corcett.I agree to tomply with all County invesfigarion Fea 7�
ordinoafes and Sfafe laws relating to 6uilding tonatructlon, Totol Fee / ' 0 0 LDMA Per�,,.q
Q an eby uthori r �saMatives of this County ic emer
$ up, f�-m ti d p',ro_perfy for inspection p rpose
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