HomeMy WebLinkAbout0957A (7) � WORKERS'COMPENSATION DECLARATION ^
� 1 hereby affirm that I have a certificate oF tonsent to self qpp��CATION FOR BUILDING PERMIT �
insure,or o certificaie of Workers'Compensation Insuronce,
or n cartified copy thereof(Sec.3800,I.a6.C.� COUNTY OF lOS ANGELES BUILDING AND SAFETY
PolicyNo. Compony
� Cor;ifiod cOpy�a hereby furnished. FOR APPlICANT TO Flll IN BUILOING �
noo�ss 0�'['i !3 rt.�
� Certified copy is filed with the county building insper g���p��
tion deportment. ADDRESS p �/ N ! oAD
Data ApplicoN � CITY O/ M ZIP f �(� ` �('j,/�. .
IOUtITV
CERTIFICATE OF EXEMPTION FROM WORKERY � NO.OF BLDGS. NEAREST
COMPENSATION INSURANCE� StZE OF LOT NOW Onl L � CRO55 ST.
(Thii section need not be comple�ed if the permit la for one ASSESSpg
hundred dollan(5100)or less.) TRACi BIOCK LOT NO. Mqp gpq� p,qGE PARCEI
TEL. �T �
I cartify that in the performance of Ihe work for which this ��E * ' 'v � �P��'�� 2� ryp' .
permit is Issued,1 sholl not emplo ony penon in ny manner qDDRE55 09 ,t .r SPECIAi ��
so os to b om �ubjetl to the u ke ' fion Lawa, - CprypRipHS 0
�� / CIIY / ZIP /%�� V
Dafe - Appliwnf ARCNITECf ON TEL. �7.'
NOTICE O A PLICANT: If, pfter oking this Certificole Of N INEER p�p DISTRICT GROUP TYpE FIRE PROCESSED BY p
Exompfion, you should becom�subjed to�the Workers' CONS� ZONE F-
Compenwfion provisions of tho Cod�,you muU fonh- � �U
wRb comply wHh euch proviaions a thii prrmit �FwH be ����
daemad revpked. � � �NT��� � STATIS ICAL CLAS$IFICA110N qpf. CpNpp. Z
IICENSED CONTRACTORS DECLARATION uC. M55 NO• DWELL.UNITS
I hareby affirm�hal�am licanxd undar proviaiom aF Chop�er 9 A�DRESS r.p, �
(rommancing with Sactlon 7000j of Division 3 of tVq Bualneµond ��G � SEWER MAP
Professions Codv,and my Ilcense ie in full fate and effect. C�iv CLA55 YALIDATION
SO.FT. NO.OF NO.OF CMECK BK. PG. ���n
license Number tla Cla:. SIZE STORIES FAMILIES � ONE z U Y.��A
YAlUAT10N
co��.a�ro� o,�o DESCRIPIION OF WORK r+�w ❑ s �9 0 0 �• •• •2 3
�I om eaempt under Sx. � Q , � • •�2 9 4
ALTER
B.BP.C.for this rw�on R��R Q S • • •3�,q�1�
oofa: us�oF
EXiSTIhIG BL�G. ^�, r e.�, �t ❑ p y,2�—g'7
Siqnatun '�'P�I�T �L. FINAI �
OWNER-BUILOER DECIARATION ��NT � + N .9/ Id/•/663 � : p,dTE �
I hereby affirm Ihat I am ezampt from Ih�Conhxtor's liten3e � - � ,
law for Ihe following reoson(Section 7031.5,Bualness end ADDRESS,Z09�f�r�,tW/ . _ C�. �/Ip HNAL �'
Pro(eteiont Code)� p By �
� I, as owner of tho rp pr or m em lo ees with BUiLDING
P P �Y� Y P Y ADDRE55
waqe3 aa ihair aole compensafion,will do the work and �
Ihe structure i�not intended or offerad for wie(Section �aA��TY �
7044,Business and Professions Code). MOVING TEi.
� 1,as owner of the proparty,am exclusively contracting ��TRACTOR NO. �
with licensed controctors to construct the project(Sec- qDDRE55 ��
tian 7044,Business and Professions Code�. ��
CONSTRUCTION LENDING AGENCY g�gqCK YnRD HWY T�ApROP��NE WIDTH �i1 �
I here6y affirm�hat�here is a construction lending agency for FRONT 1���
the per(ormonce of Ihe work for which this permit n issued p.�,
($et.3097,Civ.C.). SIDE
P.L.
Lander's Nome
LDMA Ref.tl
m Landar'a Addresa P.C.Fea S .2. aermi�Pee �
� I certify that 1 have read this application and state that the . Iss�a�ce Fee IDMA viC M
obove information is coirect.I agree to comply with all County Inre»�go��on Fse
� ordinances and Staie laws rslating to building constructlon, ioral Fee
& d hereby authoriz representativea of�his Coun�y to enter ���m�*
Z u on e o 4me io�ed r perry for iny�ction p�
� ,
� / SEE REVFNSf FOR EXRJINATORY LANGUA6i
Siqnatvre of Applimnt ar ApeM ro
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