HomeMy WebLinkAbout1228A 9552A /
WORKERS'COMPENSATION DECLARATION � �J �
� 1 hereby offirm-t6at I,hove a«.,,�,�o,e of�o�,B�,,o,e�f qpp��CAT14N FOR BUILDING PERMIT
msure,or a cerlificale ol Workers'Compensotion In ront :,�
or a cenifiad copy rhereof(Sec 3800, tOUNTY OF LOS ANGELES BUILDING AND SAFf7Y
Volicy No. Company
� Cenified copy�s hereby fornish FOR APPUCANT T�FILL fN BUILDING •
� Certifiad copy is Tiled�w'h f n �rr��ir}�c g � j
ADDRFSS a a,�s �.
tion depanmant. �[�i 9 ,... E „� Z-Z C � /2
DaH. . _.... . I' .�. ��O��� CITY � l4{� is 1 r�
� 'Q ZIP LOGUTY
CERTIFICATE OF E%EMPTION FROM WORKERS' SIZE OF LOT �'���''S' NEAREST
COMPENSATION INSURANCE C NOw ON LO7 � CROSS ST.
(Thi��sc�ion n�od not b�comploqd if the psrmif if for ane tRA� � 7g g�aK lOT NO. ��R
hund��d d011an�SI00)o�IBfl.) .. . NNP BOOK � PAGE 7ARCEL
I c�Nlfy thoi in�he performence of the work for which thie �ER � �i��" '7 ��,y oy- �/��� p�p, �Da�3�
permit ie is�ued,1 sholl nor amploy any pe�son in ony monner qDDRE55.� � l� Q J 1� � ��� �µ �
•o os to becoms�ubjen fo ths W om n�on lawa. CpNDI710N5
��Dote��Applicont CITY • ' � fJ� ZIP � (/ U
NOTICE i0 APP(ICqNi: If, oh mCkln �thi�GrtifiCole of ARCHITECTO (� T ./ Q.'
fl N INEER � ANy � p �STR�R G&OUP OP�T zRE PiiOCP$SW 6y Q
Exrmption, you �hould becoin� wb�ect to the WaVwn' �� !D �� � U
tompo�scllon provisiona of�ho Labor Cods,yov must forth• qppR�S 00 O� �� i
wlih comply with euch proviaions or this po�mit �ha14 60 . �� � - �
. ..-..... .... .-... .. ..... .h���� ..��y SfAT15fiCAl CIASSiFICATION
dromad reroked. �pNTRAnOrs � �. 00. y
IICENSED CONTRACTORS DEUARATION.. 6N�� , ��'� _ Q�. � Z
1 Aora6y affirm�hae I am lieenaed undar provitions ot Chepfor 9 �D�RESS ,-r fNp� a��� ��«�UNiTS
(commencing wirh S�pfon 7000)of Divn�on 3 0l�he Buunwt ond . �D .^ � ��C. SEWER MAv
Rofeanions Code,ond my ficsnae is in full face ond effect. Cii cu55 YAl10AT10N
50. NO.OF NO.OF CHECK �' �'.
LiconN Number � L�io.Glacs SIZE �7 STOkIES � FAMIUES ONE
CAntro[to� �ESCRIPTION OF WORK w C Jx/Vt NEW VALUATION z 1 2 2&A
oo�a /c s 2&'S on7
� ❑I am exempt under Sec fp 7.3 �� ❑ � #• • • •L 3
AITER ❑ I •�2 4 3 8
. B.B P.C.for t hi3 roown RFPAIR � :
USE OF ❑ �C 4�;�O u
��8� EXISTING BLW. DEMOL ��
Siqnaluro APPLKANT ` • 7E1q. �a�G_�$
OWNER-BUILAER�ECIARATION PR�NT p�p,/� � FINAI.
I hereby affirm thot I am exempl from the Contractar's iicense DALF� 2 �d
Law fu�he foUowi�g reasan(Set�ion 703L5,Businau aod ADORE55��1(I �. O��A�� !{ C v.
Professions Code): �� � �
�.� (, as owner of tha a � BU401NG �
p� pe fy, or my employeea wifM ADDRE55
wagas as thai�wle compansation,will do the wo�k and � z 9��2 A
ihe strocture is not intended or oflered for wle(Section ����T�'
7044,Business ond Rofessions Code). MOViNG TEL.
� 1,os owner of the property,om eaclusively contwcting CONTkAROR Np, �r r � � � ��
wi�h licensed contraotors ro construct the project(Sec qooResS
iion 7004,Business and Professions Code). � 2� �9���
RE(]UIRED TAi TBAC
CONSTRUCTION LENDING AGENCV SE7 BACK YARD HWY pROP.UNE WIDTH � � � � ���i,.��
I here6y offirm Ihot there ia n construction lending ogency for iRONT
the performonce of�ba work for which Ihis parmii is issued p.i. ��O,�`�9
(Sec.3097.Civ.C.). SIDE
P.L.
Lendar's Name
'J O�•1 D LDMA Ret.k
m Lender's Addresa P.C.Fea S �Z �ermi�Fee •L 0 V �
0 `��]
I tenify thaf 1 have reod this application and atole thot the Ig �0. � iaaua�c�Fee �r �' V DMA P/C M
o above informa�ion is correct.I agree to comply with all County ��„�i;��ion Px
S ordirwnces and Sio�e lowa�elotiny Io building construclion, Taiol fae
� o ori representatives of this Counry�o enter � •3 d �DMA Verm.Y �j s
� uPon fha abo n�ion proper for ins - n purposes. � �,, ��/} � � � �
... 4" `. �/�I �J LFi RlVfi�fi fOR EX►LANATORY IANGU `�� (I .
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