HomeMy WebLinkAbout1222A 1223A (9) � . . N/f)RKERS'COMPENSATION DECLARATION � � ^
� I yere6y affirm thot I hova o certificate ot consenl to.a�� qpp��CAT10N F�tt BUILDING PERMIT �
1 ipsure,o�a ceniticote of Workers'Compensation Insurance,
or o certified capy�haraof(Sec.3800,lab.C.) [�UNTY OF LOS ANGELES BUILDING AND SAFETY
Polity No. Comppny
� Certified capy is hereby fum�shed. FOR APPLICANT TO FILL IN ������ f '
ADDRE55 Z ZZ/p /n+ 1 R�
� Cenified copy ia filed with tha county building inapec- BUILDING "�
liondepartmenf. . ADDRESS �z2/� 1 J� j � D���y/„ (� �ryM1
Dale Applicant CIiY y�14'M�N(,� /,�� ZIP LOCALITY ���++0� ��
CERTIFICAiE OF EXEMPTION FROM WORKERS' NO.OF e�oGS. NfqREST
COMPENSATION INSURANCE SiZE OF LOT (�� NOW ON toi CRO55 5T. �i,p��r gQ /Vl�
(ihis section nead not be completed if the permit is fw one T�� � BLOCK lOT NO. ��R
hundred dollors(S10p)pr less.) � MAP B001C PAGE PARCEL
TEL U ONE hV•F
I certify that in the performance of fhe work for which this ON�NER �I � . Np, ryp � 3
permit is isaued,I shall nof employ ony penon in any manner qDDRE55 S Ma.��' L'7 �—1 ���A� �'
w as to become subjM to the Worksri CompensWion tows. �0 CONDI710N5 3 6 Z, �
�Da�e���+ Apptimnt CITY ZIP 9/7 8� V
NOTICE TO APPLICANT: If, uhar making thie ertificote pf ARCHITECT OR TE�� pO DISTRICT GROUP TypE FIRE VROCESSED BY �
ENG�NEER �UI ,Pj NO.S// '�� �
Exemption, you should becomo subjecl to the Wwken' . �1 COr1Si. ZON
GOmpananlion provisions of the labor Code,you muaf forlh- qDDRE55 /� J W
wi�h comply wi�h such provisions or Ihis parmit sholl ba � TE� �-
deemed revoked. . �pryT�p,�{p� / NO. STA7ISTICAt CLASSI�ON qpr. CpNpp. Z
LICENSEDCONTRAGTORSDECIARATION �K_ QASSNO. DWELL.UWtS
I hereby offirm thot 1 am licensed under provisions of Chapter 9 ADDRE55 � NO.
(commencing witM Saction 7000)of Division 3 of�he 8usinass ard ��� SEWER AAAP �
Professions Code,and my I�canse is in full force a�d effxi. C�iv CL455 � VAi1DATION
SQ.FT. NO.OF IVO.�F CHECK 8K. PG.
License N�m6er Lic.Class 512E �U6 STORIES '� FAMILIES ONE
Q VALUATION �
Ganhactor Date DESCRIFt10N OF WaiK NEW i�d O U O� z� 2 2,L A
ADD
❑I am exempt u�der Sec. ��r � � �+� Y� AIiER � -: #• • • �,%3
B.BP.C.for thia reawn ,n•���
V�� REPAIR � f • ,� �,7.��
Data: EXISTING BIDG. �� ❑ i
Signoture A���i TEL. FINAL •• j 6�i.f''�� �
OWNER-BU4CDER DECLARATION PR�NT �' DATE �� �
1 hereby affirm that I am exempt from the C.ontractor i License � G u G y—C G
Low for ihe following reason(Setlion 7031.5, B�siness ond A�DRE55 FINAI
Proieeaione Code): .. . gy �
� BUILDING
I, as owner of the property, ar my employees with qppitE55 „L7� '
woges as fheir sole compenwtion,wlll de the work and [
1hp slrutlu�e is not intended or olfered for sale(Sacfion ����TY
7W4,Businesa and Vratexions Code�. MOViNG 7EL. �' ♦ �� 2 1.J,ti
� I,as ownar of Ihe praperly,om exclusively conhacting CONTRACiOR Np. � y,.,�.ry #• . . s . 1
� U�x,_._
with licen�ed to�tractors to construc�tFe p�ojett(Sec- qDDRESS
tion 7004,8usiness and Professions Code).
RE�UIRED TqL SEiBAIX � °L G a V O
CONSTRUCTION LENUING AGENCY �7 gq� YARD HWY pRpp,�INE WIDTFI
I hereby offirm thot ihere is o construction lending ogency for pg�T • •C G C����C'�
�he performance of the work for which this permit is issued p.i.
(Set.3097,Civ.C.)• SIDE 0&2 9—8 8
Lender's Name
/✓O✓�^ P.l.
L�hAA Ref.�
m Lander i Add�ass P.0 For S •� ve�m��c� i� �
� 1 certify that 1 Iwve read thia applimtion and state Ihat ihe Issuanco Fae a� WAAA P/C N
above infortnotion is correct.1 agree to comply with oll Counly Invaitipanon fes �`��
'q ordinances and Stole laws relating to buildinfl construclion, To�al Fee O LDMA verm.N
R and here6y authorize repreaentativec of ihis Counfy to enter
� �po�the obove-mentioned property for I�spettion p�rposea.
m —29—�jg Sifi RfVFRfE FOq EX►LANATOItY LANGUAGE
$ignCNr �Applicant or Aq�n7 p�e
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