HomeMy WebLinkAbout1536A (8) �� ,/-� � WORKERS'COMPENSATION DECLARATION �
I here6y offirm thpr 1 have a ceriificate of�o�=e�,�0 58�, qppL�CATlON FOR BUILDING PERMIT
. insure,or o certificote of Workers'Compen3lion Insuronce,or
a certified copy�hereof(Sec.3800,Lab.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Ce�tified copy is hereby furnished. 6UiiDING � � /
FOR APPLICANT TO fILL IN AODRE55
❑ Cer7ifieP wpy is filed with ihe county building inspeo- BUILDINGrJ�} S� � +L.�� �� �aq��N •
tion de artmenf. ADDRESS L J
Octe Applimn� CITV!/�/'�/"'L�'v��� �I��fqr'�+ %� CRO5555T. '
CERTIFICATE OF EXEMPTION fROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE Of lOT NpW ON LOT O� MAP BOOK PAGE PARCEL
(This section naed not be compleled if the pe�mil is for one / ` u5E zONE MAP
hundred dcllors($100)or�ass.) TRACI l BLOCK LOT Np �-J - - Np �
// �.T/a/, . /Gi/,� r7/ SPECIAL �
I certify Ihat in the parformance of the work for which this y ��� ��l W CON�ITIONS O
r
permit is issued,I shall not employ a�y person in ony manner e�]� ��//"��a �/�� Q{) �ISTRICT GROUP TVPE FIRE PROCESSED BV V
so as lo berome su6ject to the Workars'Compensation tows. ADDRESS4 •�L>•� r� r—=•+ � CONS7. ZONE �
Dpte Appliconl CI��R � �ZIP TE � TISTI LCIASSIFI TION q , [ rypp. V
NOTICE TO APPLICANT: If, ofter mokin Ihit Certificafe of �"l� " �1[f�t7
Ezemption, you ahould become su6ject to the Workers' ENG�NEER �/�.�F—S N ��fY�/` NO. DWELL.UNITS_ W
Compensation provisions of�he Labor Code,you mus�forth- Sy�{�� ��j�je[,�.� �
with com I wilh such SEWER MAP y
p y provisions or this permil shall be �
deemed revoked. Cor�reacroa Np. BK. PG, VAIIDATION
IICENSED COMRACTORS�ECLARATION LIC. -
1 hereby affirm thpt 4 am{icensed under provisians of Chopter 4 � ADDRE55 NO. ypLUATtON
(commencing with$epion 7D00)ot Division 3 of the Business and ���
Professions Code,nnd my license is in full force and effect. piv C�A55 � S QQ��Q'
$p.F7 NO.OF ryp.pF CHECIC
license Number Lic.Closs 5¢E STORIES FAMILIES � ONE 2� �5�,�h'
ConKacto� Dale DESCRIPTION Of WORK y•�/�� � NEW ❑ E
�•• • •23
� I am exempt from�he licansing req�irements as I am o ADD
licensed architea or a registered professional engineer AliEe FINAL � •4 5 2 6 3
acting in my professionol capacity ($eclion 7051, � DATE
� BuSinBsS Ond GrOfe55ions COl10�. REPAIR � �
USE Of `�r F�NA� •4 5 2 f%J cSi
E%ISTINGBIOG. �/_�17 DEMOL �
lic.or Re9.No. Dale APP PRAN I� i�w /L i•.,[�E.i��p BY fl 4.1 3—c S
OWNER-BUILDER DECIARAFiON 6�'�1/`dC.]71�t d/v
1 hereby affirm that 1 am exempt from ihe Conirac�or's Lirense � Jz�,����( ��� (�(/"j/`f�'
, Law for ihe following rea5on(Section 7031.5, B�siness and AD Fss
Professions Code): .
❑ BUIIDING
I, as owner oF ihe property, or my amployees with q�DRE55
woges as their sole compensation,will do ihe work and
ibe sirucNre is not intended or offered for sale(Secrion LOCAIRV
7044,Business ond Professions Code). MOVING iEl.
� I,ps owner of Ihe properfy,am ezclusively conlrpcting CONTRACTOR NO. � '
with licensed contracbrs to mnsfruct the project(Sec- qpDRE55 �
tion 7044,8usiness and Professions Code). �'.
REQUIRED TOTAL SETeACK fROM E%IST. �
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE WIDTH '�
I hereby af4irm�ho��here is a mnsiructian lending aqency fo� FRONT "
the performance of the work for which this permit is issued p.�
(Sec 3097,Civ.C.l� S�DE
P.L
Lender's Nome �
_ lender's Address P�-Fee 5 Perma Fee �
I certify rhat I hove read this applimtion and stme fhat the issu ce Fee -
Qabove information is correct.I agree to comply with all Counry ���esiigation fee
ordinances and State laws relotin9 to building mnsiruction,
� and hereby a�thorize representatives of�his Coumy to enter Toral Fee
� vpon ihe above-menfioned property for inspecfion purposes.
SEE REVERSE FOR EXPLANATORY LANGUIIGE
Signature oi AppLmm or Agent �ate
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