HomeMy WebLinkAbout0913A 1012A (4) � WORKER$'COMPENSATION DECLARATION .. . ...-...... ._ . `V f��� f�
� ' P APPLICATlON FOR BUILDIIVG PERMIT ��;
reby affirm �hat I have a certifico�e of consenr to x1I
fure,or a certificate of Wwkers'Com ensation Insurance,
�r a certified copy theroof(Sec.3800,�ab.C.� , COUNYY OF LOS ANGELES BUILDING AND SAFEiY
PolicyNo. Gompcny - .
� Cartified copy is heraby fomished. � fOR APPLICANT TO FILL IN BUILCIING �7 '
ADDRESS Q� � �IY� � !L
��- '❑ Certifiad copy is filed wilh fhe[ounty building in6per .�:� BUILDING �2 � � � t-�
� lion depOtfineM. _ � ADDRE55 � �}�
r 'T��.� �
Dole � ApplieaM � CITV /1 1.,J�'�7�---ZIP IOCALITY Q�(\
CERTIFICAIE OF EXEMPTION FROM WORKERS' SiZE OF LOi NOW ONB LOTS CRO5555T. � Su � I<<
COMPENSATION INSURANCE� �
(This secrlon need no�be complated if tha parmit Is for ona iRACT BtOCK �Oi NO. �ESSOR
hund�od dollor:(5100)ar IBli.J L A y M�P�� PAGE PARCEL
� � � - " OWNER S�'1'1 C!!p� NO. ��✓�l�,�C USE ZONE
I crrtify thm in ihe performance o the k for �ch t �a � tJ ��
parmit is issued,I shal)nol employ rt n in on mon r pDDRE55 ,3 DKL{ ��� �
so m to CO e fubjeN f0 Ibe WO penwt n t a. CON�ITIONS �
� � . � CITY /�� ' ZIP
Dots A ��� ARCIiITKT OR TE�. �ISTRIR GROUP ttCE FIRE PRO�SSFD BY �
NOTI TO PPLICANT: If, ahar making�thi�C rtffico of E��NEER NO. ap Z� �
Eramptlon, you should becoma s�b�ect to Me on' V
Comprnsation provisiona of ihe labor Code,yov mu�t toAh- qppRE55 'Q �i � � W .
wllh comply with auch prowi�ioro w Ihis p�rmil tholl 60 � �� _ nJE y� �
dNm.d rrrokrd. �oMR�Co� C /C( aS/�I� STATISTICAI CVSSIFI TION APT. CAN00.
LICENSED CONTRACTORS DECIARATION y� � �ct.a55 NO. DwFll�.uNiTS Z
LIC.
1 hereby oFfirm�hot 1 om linnt�d undar proviciona nf Chaptor 9 AD�RE55�.�a / NO. .
(canmencinq witb Sectlon 7000)of Division 3 of tha Butin�q ond IIC. ���R�
Profsuiom Code,and my licansa is in full force ond effxt. CiTv CLA55 � � YALIDATION
SQ.FT. NO.aF NO.OF CHECK
Litensa Number � Lic.CICa � SIZE STORIES FAMIlIES ONE � -- �--
�1 �un � J � vraunno►�
ConIfOC10f DESCRIPTION OF WpRK `eC/YL NEW ❑ i �.S QrA
A� V
�I pm ezempt under Sec. �
ALTER
B.BP.C.fof lhif raown REPAIR :
z
Date: EX�ISTNG BLDG. �� DEN�Ot `C �.�p
APPLICANT TEI.n ..1� // j{• • . •2�
SignaWre . . . PRiMT e SheeC NO.o����Z FINAL -.
OWNER-BUILDER DECtARAiION � DATE �/. ��
I hweby afflrm that I am exempt from tFw Conhactor's Licsnse C..,t, I' � a •2 7�6�
Low for the following reoson(Srction 7031.5, Business and ADDRE55 [� � r.�(� l� iINAL � .��
T �/, • . •
Vrofrssions Codey: .. . .. . . ....._... /C�IS!"�^ -�'�� eY � �1.fJ J�
❑ BUILDING /1
I, os owner of the property, or my amployaee with ADDRE55 - �B,�y�"8�
woges a�their mle compenaafion,will do!he work ond �
the slructure ia not inlendad or offared tor:ale(Section ����T� � . �
7041,Businacs ond Rofessions Code�. hwv�NG � 7E1. �
� I,os owner o4 the properfy,am axdusivaly coMroaing CONTRACTOR NO.
wirh licensed controc�ors to consiruct the projecf(Sec- qppRE55
tion 7044,Business aad Rofessiuns Cnde). � �
CONSTRUCTION LENDING AGENCY gT gq�K�� VAR� HWY -TO7�rM10PA�NE WIDTH .- _
1 hereby affirm that�hera is a construction lending agency for cROM
the performance of the work fo�which this permir is issued v.�. z 1 D 1,2 A
(Sec.3097,Civ.C.). sioE
P.L. #��� ���
lendai s Name IDMA Re4.M I • ��1 3,�i(�
� � P.C.fee f Pmmir Fen ��.
�a�.•5 ndd�eu (� •• •4�,0 D�
� 1 carti at 1 h e this applicotion ond slate ihal Iha I�swnw Poa J LDMA P/C M �
� infwm ' n i corr t.I ogre mpiy with oll CountY Invesiiqotian Fae ��2�`8 7
'q o�d n d S e I s relati ta b ing construction, To�al Fea O LDMA Perm.N
R a ere y aufh ' esentat es of th Counry to eMar ,
� a eh i ne praper for in ction purposes� 'I
� �- �7 fEi YEViRS!fOR El(RANATOlY IANGUAGf '�,.
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