HomeMy WebLinkAbout1302A WORKERS'COMPENSATION DECLARATION �
� 1 heraby affirm ihat 1 hove o certificate of tonsent�o self APPLICATION FQR BUILDING PERMIT
insure,or a certificate of Workers'Compensotion Insuronce,
or o cenified copy theraof(Sec.3800,tab.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Compony
� ce.��fied�oPy�z he.a6y fu.��shed. FOR APPLICANT TO FILL IN Ao�R��ss Z'7�" S � �/e,r�"
� Cer�ified copy�o filed with�he couny building inspeC- BUIIDING �r G' A
tion deparfineM. ADDRE55 /� LY(�
Dote Applicanf Gitt C� , 4� ZIP l 7b.? tOCAUTY �Q�D fi� (�r �t�
CERTIFICATE OF EXEMPTION FROM WORKER5' S�ZE OF tOT NOW ON LOi GRO5555T. Y"T7 C� 6�`
COMPENSATIpN INSURANCE !�
(This 7edion naed no1 bY tomploled if/he permil ie tor one ---- TaAR- �� BLOCK LOT NO. '�ESSOR
hundred dollors(StoO)or less.) nwa aoac VAGE PARCEL
TEL. �. �?ONE �
I certi(y�hut in the performance of Ibe work for which thia OwNER � R �j" NO. �
permit is lasued,1 shall not emplo any prrwn in any monner 5 SPECIAL
u w to co s tu6ject Io tha orkers �q�ip��p�ys. A�DRE55 6.. CONDI710N5 p
Uo�e � ��nppiica �^-' � c�rr z�v �
ARCNITELT OR TEL.
NOTICE i0 APPLICANT: If, ofter ing this Cerfificat�of NGIN ER pp WSTRIQ GROUP TYFE FIRE PR gy p
Eaemprion, you ahould becom� w6jecr �o tha Worken' �� COWT.�tt'�� �E � W
Compansation provisians af fha Labor Codo,ypu myit forth- qpDRE55 V N
winc �omply wirh such provisiuns or this permit shqll be � TEI. STAtISTIG4l QASSIfKATION Api, CONpp, t�p
deemed revoked. . �ONTRACTOR � 4r a mt711/�_ Np���"7i77]� Z
IICENSED CONTRACTORS DECLARATION ��y y_ �K,.., QASS NO. DWEtt,UNITS
t here6y affirm�hat{am liceraed under prnvisions uf Chnpter 4 noo�55v"p y �QDCK.���L�/'pp,i'� 937
(tommencing witM Sectio�70b0)ot Division 3 of the Businast and � ��� �wss SEWER MAP
Professions Code,and m I�censa is in f�ll torce and effan. cin D VALIDATION
50.R. ND.QF NO.OF CHECK gK' �''
License Number 3 31 Q�7 �i�,�lass� SIZE STORIES FAMI IES ONE
❑ VALUATION
�It �F.SCRIPTION OF WORK H� /
Conrrocror k 1'+[ZJ�l/P pote s !O a a b'
�I am exempt under Sec. '�� �'�'�l p ADD � �
� r ALTER �
B.&P.C.fw Ihis reawn 1. -y ��� � f
BEPAIR
Dare: use
EXIS7ING BL�C'i. �FMa ❑
Sigratura �PR' I�NTT q. d7'H ini0 I�L� f FlNAL
OWNER-BUILDER DECLARATION y DATE �j�up��
i heraby affirm iFwt I am eaempt from the Coniracior's Limnse qpDRE�S!i S- y[���fr� ��^
Law for�he following reawn(Sedion 7031.5,Businass and FNAL
Professione Code)� ....._ ... ..... ..... ........ . p� . . . �� � -�
� BUILDING
I, as owner of�he property, or my employees with qpp�u
woges as their sole compenmtion,will do the work and � �� W�c ri
Ihe shuclure is not intended o�offered for sale(Section ����TY
7014,Business and Professions Code). � MOvtnKi TEI. �. . . W , �
� 1,as Owner Of ihe property,om exclusively conirocting CONTRAROR Np.
with licansed contractors to construct the projec�(Sac- pDDRE.55 � • •6 1,7 5
lion 7014,8usiness ond Professions CodaJ.
CONSTRUGTION IENDING AGENCY �gqq� YARD HWY T�TApROV.LCNE WiDTH �� �� �'�J�
I hereby affirm that there is a consiruction lending agency for FRONT �i 9,01 —8 E
Ihe parformantt of Ihe work for which-fhis permil ia issued p.t.
(Sec.3097.Civ.C.). SIDE .
P.L.
Lender's Nome I lpMq Ret.N
m Lender's Address P.C.Pee� Pormi�Fee �
� 1 cartify thaf 1 have reod Ihis application ond state thot the Issuance Fee LpMA P/C k
� 0 6 infama�ion is corcea.I agree ro comply wi�h all Counry InvratigWian Fae � �
q rdinances and Stote laws relaling to building construclion, To�al Pse �
nd hereby au or"e repreaentalivas of lhis Coun�y to enfer LDM4 Verm.N
< n e a e- ntioned property for inspectio p poses.
m � /iv�•-� �� SfE REVFRSE fOp EXrLANATOiT lANG11AGE
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