HomeMy WebLinkAbout1000A (9) � WORKERS'COMPENSATION DEQARATION � " ' �- . " �
!�,��eba�°a`�e�,<<o',aofwoke5"�om'Pe�,a°o�s��;��o��e` � : APPLICATION FOR BUILDING PERMIT
or a certifie8 copy thereof(Sec.3800`,Lab.-C}.-) �� � CpUNTY OF LOS ANGELES BUILDING AND SA ETY
Policy No. Company 1�19 p �y /',
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN nooaess �0 �b` �(.l Ct- �/�>/�G • •
�� Certified copy is filed with the county building inspec- BW�DwG � , �
ti0ndeportment. ADDRF.SS � �/n.� tocnun � Q � on� ���
2— c"a�ossSST. r� �.� ' (2tv G
Da�e Applicant qN I � Ziv 1��C�
� CERTIFICATE OF EXEM7TION FROM WORKERS' � NO.OF BLDGS. I nS5E5SOR
COMPENSATION INSURANCE SIZE OF lOT NOW ON LOT 1 MAP BOOK PAGE PARCEL
(This section need nol be completed i(the permit Is for one � u ZpNE �+P ] ]
h�ndred dollors(EI00)or�ess.) TRAR BIOCK LOT NO. � � �,I NO. U �1J 7
—t- TEL h� p O SPECIAL }
1 cer�ify thet in the performance of the work for which this OWNER MC�^� ilc9 •�S='� No. p�vl g� 0�� CONDITION$' d
permi�is issued,I shall not employ any person in any manner r, '�1 - - oisteici G20uv ireE FlRe PRpCE55ED BY Q
so as fo become subiecf to the Worken'Compensation Laws. ADDRE55 o2t Tt� 1 N IG �� roNS� �� e„ /� �
. � . . . � . . �CM-' � rP� i�/ 3 Y ��� ,O
Date APPIi[ant �. CITY � . .. .. ` ZIP. ... $TATISTICAlQA551FICA110N APT. CONDO. U
NOTICE TO APPIICANT: If, after m6king this Cerfificate'o4 ARCHITECTOR�,\ � '�.TEL�. � .,-... . . �/ „
ENGINEER: � ��YR1W�'�I�N�VL+=.�.� NO. �.' �CLASSNO. �- DWELL..UNITS W
�Exemption,�you should bemme��subject'�fo�the Worken' �- c . .. - . , tL
Compenwtion provisians of the Labor Code,yau must(orth= - � ADORE55 ��.Jl�`���' � �'. � '��- � � SEwER nMP �
ith comply with such provisions or ihis permit shall be 7EL.
deemed revoked. i � . . BK. PG, VAI�DATION
CONTRACTOR �G �•� /}�.INO.
IICENSED CONTRACTORS DECIARATiON � uC. •
I hereby affirm thet I om licensed under provisions of Chapter 9 A�DRE �. b� NO. �0 t'7 yqLUAT10N '
(mmmencing wiih Section 7000)of Division 3 of rha Buslness and uC. �
Profeuions Code,and my license is in f�ll(orce ond ffetl. CiTY ! i ,u. v CIn55 f p1� Q Q �
SO.FT. N OF NO.Of y CMECK
Li[ense Nu ber� � a�� Lic.Class � SIZE �� ST RIES i FAMIUES ONE ► , -
�c he. � � �/sj s
Conira[tor � �afg I DESCRIPT N OF WORK S �7.J N� ❑
�I am e.empt�nder Sec. � � � ��R � FINAL � �J , �
6.8P.C.for this reason REPAIR � DATE / ���J
Data: � USE OF p�p� � i1NAt / �
E%ISTING BL . BY �/,y��
� APPLICANT TEL. v(F+'.]
Signature OWNER-BUIIDERDECLARATION I PRIM l � � NO. �O4
I hereby a(firm Ihat I om exempt from the Conlmclors License I �� ►
Law for ihe following reason(Sectlon 7091.5,0usiness and A�DRESS �
Profeesions Code): � PR - �
❑ . BUIIDING I (� F N " '
I, os owner of 1he prope�ty, or my employees with ADDRE55 �� O Q O A
wages as their sole compensation,will do the work and . ����TM S U{�2 �tA:� �/�LM14.
the strvct�re is not inlended or offered for sala(Sectlon I — �. • . • •.�
7(144,Business and Professions Coda). MOVING TEL. � �,
� I,as owner of Ihe property,am ezclvsively contracting � � �RACTOR NO. . . _ � • �8 Q 5 O .
with licensed mntmUors ro consfruct tha project(Seo- qDDUE55
tion 7044,9usiness and Pro(essions Code). I . • e� $Q 5 p� .
REQUIRED TOTAI SETBAIX FROM EXIST.
CONSTRUC710N IENDING AGENCY � SEi BaCK YAR� FM1YY PROP.LINE Wi�TH I�� �
I hereby affirm that there is a construction lending agency for FRONT �1 U � �Q � r ` - � - ��•�2�$4��
� the per(ormance of Iha work for which�his pe.mit�s�ssued + p.�. oC ,
tSee.3097,Civ.C.�. SIDE
- � -..P.L. �
lender's Noma �j
� ( P.C.Fea f Permit Fee � /U• � . .
lender's Address c
� I tertify that I hava read this application and state Ihal the � � Issuance Fee �,,) O �, ��
a ve fnformalion is mrrecl.I agrea to comply wiih all Counly I Invesiigaiion Fea `) - �
� dinances an Sfa1e laws reloling fo building construciion, Toial Fee a ��S�
C1 ereby �o ze r �resentclWes of fhie Coonty to enter �
t O ab v t n d propeny for inspetlion p�rposes. � � �
^ - J IZ � SEE REVERSE FOR EICtLANATORY UNGUAGE � .
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