HomeMy WebLinkAbout1053 (9) � '�"� WORKERS'COMPENSATION DECLARATION �
� insurebor�afcert'ifca,teofWokesr'Comtpensotionlnsora e" APPLICATION FOR BUILDING PERMiT
a�o cariitied copy rhereo4(Sec.38W,�ab.C.� COUNTY OF lOS ANGELES BUILDING AND SAPETY
Pacy Np, Company BUItOING T' n �
Cenified copy is hsreby furnished. FOR APPLICANT TO FILL IN qppR65S � � � 2� f
� Certified copy is filed wi�h the couny building inspec- D RESS 0 V�fl !'� � „"' ' _
�ion deparlment. C
�y ApPlicont� CITV V ZIV ���J �.p�ITY q,.��rn_9-rw
CERTIPICATE OF E%EMPTION FROM WORKERS' NO.Of B�OGS. NEAREST ,
COMPENSATION�NSURANCE sie oF iOt raOW Orr LOT CRO55 ST.
(This SBcHon neYd not be completed if the pBrmit i!iq one TR� ?�BLOCK LOT NO, � µqp BOqC PAGE PARCEL
hundred do�lnr:45100}or{ea.) /� 7E1. Q .l
� pWNER Y"• NO.- ! � �� lISE ZONE � f D�J
1 cerlify Iha1-in Ihe performante of tha wwk for whicfi thia .��' �
ermif is iaaued,I shall no�em lo on enon in an manner y r� ���A� -
P P y Y P y nooaess b(C� U O � CONDITIONS
so m to b�o wbject m ths W ri Com nw�ion lowa. �
V�f arr z�P
�1e N�� i4PP���°�� qRCHI7E DISTRIR GROUF TYVE FIRE D BY O� �
NOTICE TO APPIICRNT: If, aNer making thks Certificate of ENGINEER TEL �
Ecemption, you sho�ld become eubjed to the Workeri N� "S. t-j_� ��� � V ,
Compensalion provision�of ihe lobor Code,you muat foHh- qpppE� O� li,. d�- '.
wlth tompFy with such provisions o� thii psrmil shcll ba TEL .t ! STATISTICAt MSS�FICATION APT.� CONDO. N '�,
deemed rovokad. � � CONTRACTOR �� NO.�'7 7 . � ! Z ��.
IICENSED CONTRACiORS OECtARATION ��t_- C�fj-, Cllss HO�—i—DwEtL UNITS__ � i
t fiereby oft'um thot I am ticanwd under provisior��of Ctapter 9 AWRE55 21i�i(� Yl�'� �. 3 7�T� �R� _ . ... I
(commencing wilh Saction 7000)of Diviaion 3 of the Buainess and � .LC..- - �- � � - �
Professions Code,and my licensa is in full forca ond effect. CI7Y ✓ C1.455 e� f� � � VALIDATION
�j SI p1_Z./ (�,�(a so.cr. Z No.oF ra.of cr�cK I
litense Number �` l .Closs� SIZE STORIES FAMIlIES ONE
�( �? -v�u�no++ _.___ _ i
Wv��(�� � _
ConMa[tor � " �"ti�" e 0 DESGFtIPTIOrI OF WORK ��... S I��U_
L. /��O Aoo y
�1 am ex�mpf undw Sec. /f q�TER � � r�������
8.8P.C.ior rhis reaaon �`�� 0.EPAIR � s
us�oc
Oote: EXISTING BLW. ��� �^^� �as3
Siqnorure � .. � � FINAL ��� r��. `
OWNER-BUILDER DECIARATION �PUN . A���� �EL,,���� ���- � DATE
1 hare6y offirm Ihat I am ozampt from the Conhactor's Liunss AooaE55 �L�� N'K' �/�IKW� • t�� FlNAL �� ��
law for the toliowing mnson(Section 703t.5,Boeineas and � �� /
Profeesiom Code): .. . . .. . ... . . . . �.....� ..• 3(r.�'S
� BUILDING
I, as owner of the property. or my employees with ADDRESS
wages os their sole compenantion,will do the work and � �Q"���
Me shottore is noi Intended o�offarod fo�wle{Secfion ��`��� .
76/1,Business ond Aofeszions Code). MOVING iEl.
� I,as owner of the propeny,am eaclusively cont.ocf�ng C NTRACTOR N�� �
with Itcenaed cootraclas to consiruct fhe projecr(Seo- � qDDRE55 �
tion 70�4,Buainess ond Professions Code).
CONSYRUCTION IFNDING AGENCY SET�BACK ��kD HWY T T���NE WIDTH
l hereby affirm�ho�there is a cnnakuction Iending agency for cRONT
ihe performance of Ihe work for which this permit is issued P.L.
(Sec.3097.Civ.C.). SIDE
P.L.
Lender's Namo �
IDMA Ref.�
� Lender'a Address P.C.Fee S Pormi�Fee �
$ I cerfify that I have read Ihis opplitatio�and state Iha�fhe Issuonce Fee � ��+P��y
� o6ove informa�ion is corract I ogree to comply wi�h oll CountY investiqation Feo / —7
q ordinanms and Stote laws relminp to buildinp conurottion. To�al Fee 2Co �/ �DMa v.�+.Y
and here6y outhorize ropresenroiives ot rhis Count to/ente�
� n obove-m^entioned p�spection urposas.
��1J ' fE!REVFMfE fOY iXMANATORY LANGUAGE
Sigrwture d Applicant or Agent Dala
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