HomeMy WebLinkAbout1009A 1010A WORKERS'COM7ENSATION DECL4RATION �
I hereby affirm that I have a cenificate of�o�ga�<<o.a�f APPLICATI�N FOR BUILDING P�RMiT
insure,or o cer�ificate of Workeri Compensation Insuwnce,
w o cer'ified copy rnereof{Sec.3800.�ab.c.� %'CpUNT,Y OF LOS ANGELES BWIDING AND SAFETY
Po❑Ifq No. Compony , BUIIDING
Certified copy is bereby furnished. FOR APRLICANT TO Fill GRl aooaess o? oZ �%
� Certifiad copy is filed wilh ihe couny building inspec• BUiID�NG (�, � _,(3�
tion departmanL ADDRE55 7� L LOCAUSY
/ NEAREST
Dote Applicont CITY Q m(h Q CROS551.
CERTlFtCATE OF FXEMPTION PROM WORKERS' �'�&'�' ���R
COMPENSATION INSURP.NCf SIZE OF lOT NOW ON LOT MAP BOOK PAGE PARCE�
(This section nead nat be completed if ihe parmit is for one USE ZONE �P Q p'� � .
iRAR BLOCK LOT NO. � NO-
hundnd dollan(5�00)or less.) SPEGAI a
�` a 2
OWNER ' NO. CON�I710N5
I certify tMt in Ihe performanca of fhe work for whith thie dSTaKT GROUP TYPE ctRE PROCESSED BY �
parmif is issued,t ahall not empioy any perspn i�pny manner qDORE55 � CONST. NE
so os to 6ecome wbject b tbe Wwkers'Compensotan laws. _ �� � CL
CITY ZIP�L. STATR(IG4l CIP.SSIFICATION APi. C DO. O
Date ApPlicnnt
r�OTICE TO AVPIICANT: Ii, oher making�his CenNicme of NGHNEER � �. � cinss�a. °�-� �wEu.uwn_ W
Exemption, you should become subject fo the Warkeri d
Compensation provisicro ef the labor Code,you must fa�M qpp�u SE'NER MAP M`
with [Omply with such provisions Or ihis permii sha!! be 7�, /�_ Vql1DATION
deemed rBvpked. CONSRACTOR NO. �
l¢ I� BK. PG.
UCENSED CONTRACTORS DECLARATION tIC.
I hereby affirm tFrot I om licensed under pro isio'u ef Chaptar 9 nooRe55 � YAlUAT10N
(commencirg with Section 7000)of Division 3 of the Buslnass and • tIC. �Gj
Professions Code,ond my licenx is in full force ond effect. CIN �wu s i/��
' $p.F7 , NO.OF q MO.OF CHEIX
ticeMe Number Lia Clase SIZE STORIES L�— FAMILIES ONE --- z� C�f.C1�
DESCRIPTION OF WORK N� ❑ f �}• •2 J ..
Coneraefor Oale ppp � - . ..•
�I am exempl�nder Sac. � � ryNp� � ' � � • •v I G 4
ALTER �� � p� �
B.&P.C.for thiE raoaon REPAIR � - �A� O � z z?:�G;.;-
use oF � fIHAI
Qole: EXISTtNG BtDG. �� By t���7`G'r�
Si9nolVfB APPIICANT �l.
OV+7NER-BUILDER DEQARATION ��M h �� NO- �
I here6y affirm that I am exempt from the Controcfor'�License qvo2f55 �
Law for tha following reasoo(Saction 7037.5,Bu�inata and
Profe � ns Cod�): PRE �� �'�.��
eui�ir� �j
1, os ownor of ihe properry, or my emptoyees wi�h AW0.E55
woges as ihei�sOIE compenaofion,will do the work and H� � � �
the str�c�ure is not inlended or offered for wle(Section ��°'��TY
70M.8usiness and%ofessions Coda�. AACriING TEL. � • •4 9,2{
� 1,os ewner of�he poperty,om exclusively contmding NTRACTOR �� .
with licensed wntrocrors to construct the project 45ec- • � ti 4 y,c���
tion 704.8usines�and Wofessiona Code). ADDRE55
REWIRED TOTAL SETBACK PROM EX�ST. O G L�J�C Fi
CONSTRUCTION LENDING AGENCV SET BACK �ARD HWY pgpp,�� wIDTH ►
I hereby affirm that the/e is o construction lending agency for FRON7
the performance of�he work for which this permit is issued P.l.
ZSec.3097.Civ.C.). 51�
P.L.
� Lende/s Nome ,j} �} 7�y �e�
S P.C.Fea S JL•/ Permir Fae •�"� ��
` te�dars add.as� �v�
� I ceAify tlat 1 have read this appliwtion ond stata that the issuance Fee
� above informatlon i�correct.I agree to mmply with all Counry Invaaligalion Fee /�p
ordinoncas and Siote lawa reloling to b�ilding conatruction, Total Fee 7 /•Z'�
CJ and hereby authwize repreunw�ives of this Counly to enter
� upon tfw abov�me�rio�ed proparry f r i�sp ction purposes.
�O e��� �"'�� SFi YEVElSF FOR EXHANATORY LANGIIAGE ' �
� ����of Applican�w Agent�� Date � . �,
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`o`� .II« � :c�, o�n.o���~� � 0 � ��+�..'�~ � �` o N"�� �.^. . r � .
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