HomeMy WebLinkAbout1094A WORKERS'COMVENSATION DECLARATION \
insure,borafc�ertitica�elofWorkerseCompensffonlnsuroncesolr � APPLIGAT6��N FOR BUiLDING PERMIT �'
a cert�fied copy thereof(Sec.3so0,�ob.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY
�cy No. Compony eUILDING
Cerdfied coPy is hereby iurnished. FOR APPLICANT TO FILL IN A�DRE55 ���
� Cenified copy is filed wilh the toonfy building inspeo BUIIDING /� /J n �J_� n /�
iiOn departmenf. ' ' . ADDRE55 / �� S. /C L /"�/(�(��J' /�GC. LOCALITY �.4�.�.-� t-L/�./�
9' / � NEAREST
Date Applicant � ' CITV ZIP Y CROSS St.
CERTIFICATE OF ExEMPTION FROM WORKFRS' - NO.OF BLDGS. , ASSESSOR
COMPENSATION INSURANCE S�ZE OF LOT S ISO NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not 6e completed if the permit is fo�one USE ZONE NOP ��7 `f�
hundred dollars(8100}or less.� TRAQ /J BLOCK LO7 NO. �'� �
/ iEL tL �/ �/ SPECIAL y�
OWNER S/l(� �.�p,�T��IT �rT� CONDITIONS
I certify thoi in the per4ormance of�he work for which this V
permit is issued,i-shall nof employ any person in ony monner p l/1J DISTpIGT GROUP TVPE . FIRE 7ROCESSE�BY
, so as to became subject to the Wo�kers'Compensorion Laws. /ODRE55 �s K B �✓{,r !�K, !O �� cONSL r 20NE O
��/� 0 zT
Date Applican_ • a�^' GTY �� � Z�P ��7G SiA715i1CAL CLASSIFlCAiION APT. CONDO. V
NOTICE TO APPUCANT: If, after moki this Certifimte ARCHITECS OR iei. q �
Ezempfion, you should become 1u6jecf to iRe Worke ' ENGINEER NO. QA55 NO. �-i OWELL.UNITS__ N
Compeasation prorisions of the tabor Cade,you must forth- qDDRE55� �� �� � �- - SEwER hWF Z
with comply wilh such p�ovisions ot.this permit.shall 6e TE� �
deemed revoked. CONreaCrat � NO. BK. PG, � YAUDATION
LICENSED CONTRACTORS DECLARATION � IIC.
I hereby offirm ihat I am licensed under provisians of Chop�er 9 ADDRESS �� �VALUATION
(cammencing with Sedion 7000)af Division 3 of the Business ond � ���_
Profass�ons Code,and my license is in foll force and effed. CITY C1A55 s ����
SQ.FT. NO.OF NO.OF CHECK
Litense Number Lia Clau SRE ��O U� STORIES FAMIUES ONE
_! S
Contractor Date ' DESCRIPTION OF WORK D G•��r NEW �
� / G �/OL2cSP�� ADD �
1 am ezemp�from the liwnsing requirementz as I am a
licensed archirect or a ragiftared protessional engineer AITER � FINAL � �
octing in my profes�iona� copacify (Section 7051, REPAIR � DATE �
Business and Professions Code�. USE OF
� EX�STING BIDG. DEMOI � FIN L
Lic.or Reg.No. Date APPLICANT TEL �d gr
QWNER-BUIIDER DECIARATION PRINT) �E /� NO.07��Zq �1 0 9 4 A
1 here6y affirm tha�I am ezempt frord the Connactor's License aooRe55 T�S S. /!r ek ,�I V*r /c6(_, �" ��
Law for the following reospn(SeClion 7031.5, Business and tt���►��� .
Professioni Code):' PR
�- -I, as owner of the propeny, or my employees with nooRE55 - � � �31.5 0
woges os�heir sole compensation,will do the work and LO�uTY •��TJ��J��c�i
the siructure is no�in�ended or offered for sale(Sec�ion
7A44,Bosiness ond Prafessionz Code). MOVWG TEL.
� I,as owner of the properfy,om exdusively mntracting CONTRA[TOR NO. �2 2 2�8,�
wilh licensed mniractors to consirucf the project(Seo- qD�RESS �
tion 7044,Bus�ness and Professions CodeJ.
REOUIRED TO7AL SET9AIX FROM � EXIST.
CONSTRUCTION LENDING AGENCY Sei BACK YARD HWY PROP.L!NE WI�7H .
� I hereby a44�rm thar there is a mnstrocrion lending agency for . FeOrvT
Ihe pedormance of the work for which this permit is issued P.�. �
(Sec.3W7,Civ.C.)� SIDE - -
v,i.
Lender's Name ._ . . .. _. . . ,�}
$ P.C.Fee$ Permii Fee ,f��
Lender's Address o//J
I rerfify fhol I hove read lhis oppiication and siote that Ihe Issu ce fee /•JV
Qabove information is correu.I agree to comply wilh pll CooMy Inrestigation Fee an /�) .
ordinances and Staie lows rela�ing to building mnstruction, Toial Pee ,3�.�ryU
� ond here6y authorize representotives of this County to enler
m upon Ihe obo�e-mentioned properfy for inspecfion purposes.
� X�,/, //((/YV L�J �2' L2- 8� SEE REVERSE FOR EXPIANATORY LANGUAGE
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