HomeMy WebLinkAbout1420A (15) WORKERS'COMPENSATION DECLARATION �
I hereby affirm thar t have o�a�;f;ro�a of�o���„o Se�f . AP��.�CAT�ON FOR BUILDING PERMIT
insure,or a certificate ot Workera'Compensation fnsurance,
or a ceniiied copy thereof(Sec.3800,lob.C.) COUNTY OF LOS ANGELES BIJILDING AND SAFETY
Policy No. Company � �'�'� n /�
� Cer�ified copy is hereby furnished. FOR APPLICANT-70 fllL 1N - qooReSS .l �t o4'n.
� Certified copy is f{led wi�h tha county building inspec- BunDING C J?�l�/ If �p
tion deportment. � A�DRE55 J Cl��� I` �� lOG4L17Y '�J.
NEAREST
Da�e Applimnr an �A'� � k z�r ( � caosssr.
CERTIfICA7E OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE 512E OF l0T NOW ON lOT MAP BppK PAGE PARCEL
(This section need not be completed if The permit is for one U5E ZONE MA /� Q
hundred dollars aS100)vr less.) TRnct � eiocK LOT NO. NO. /�.�" 7
An ,E�. (I / ��J-�-- SPEC�A�
I tertify ihol in ihe performante of the work for which this OWNER /•Id NO. �7 ' (o CONDIiIONS �
permit is iuu ,I II no�employ any penon in any manner � �-- OISTRICT .GROUP TYpE FIRE PROCESSED BY 0
so as tp 6e[ me b�ect fo th or Co e fion Laws. p`��E� � � �d n_� CONST. ZONE U
(� K �
Dote � �� Applicanf . CITY '1 �P � G STAi15TICAL CL4551FIC4TION ' AVf. �
NOTICE T APPLICAN7: If, afier making this Certificate of �H�TecT O Tei. � h j ' V
-Exempfion, you ahould becoma wbjetl to the Workers' ENGINEER NO. . ppupp, aN DWELL.UNIFS_ a
Compensntion provisions of tho Lob.or Coda,you must forth• ADURESS SE4VER MAP �
with comply with auch pravisions or this permiT shall ba TE� Z
deemed revoked. cO�vrRncrqt � ryp, �4 S-' BK. �'G, VAtIDA710N
UCFNSE�CONTRACTORS DECLARATION /�� � ���. �
1 hereby affirm that I om licensed under povisiona of Chopter 9 ADDRE55 (,fJ7i NO. S�� YALUAitOFi
� (eammeexirg with Settion 7000)of Division 3 of the&+sineu end l�. �� C J
Profeuio�u Code,ond m licenx is in full force and effect. GiY �l Cv�55 L�� f ��
u
3� (.� 7 � ���/ Sq.F7. NO.OF NO.OF CHECK �
License Number r �� !fc Glau_L'+�! SIZE STORlES FAM�LIES ONE
'2� / NEW S �� 4 L,O A
ControCtcr po�o b �ESCRIPTION OF WORK
�1 am exempt under Sec. p '°'�D -❑ n s �• • ��
AL�R � FINAL l 1 a i� ( •+4'�O O
6.8P.C.for Ihis reawn REvAiR--Q DATE �\- J
�+e: usE oF �l( �enno� ❑ wwu. � ...C��0 0=
EXISTING BLOG. �Y .\�\�v :
Signature �PRIMT f EO.}( d�.��`��' �
OWNER-BUILDER DECIARATION � � �
!hereby offirm that I om eaempl from the Contrntiw's ticensa � J^ �!� ���y� �
Low for the followiny reason(Section 7031.5,Business ond /+DDRE55 ,l7 ilY��G .WKL/'✓1
Profeuions CodeJ: -
❑ BUIIDING
1, as owrrer of ihe property, or my employaes wi�h n�RESS
wages as fheir sole compenwtion,will do the work ond
Ihe structure is noi intended nr offered for wle(Seclion ����TM
7Q44,Business and Professions Code). MOVING 7EL
� (,os owner of the property,am ezclusively coniracting CONTRACTOR NO.
with licensed contracton to construct the prOle��(��- AD�RE55
�ion 7044,Business and Professions Coda).
REWIRED TOTAI SETBACK FROM EXIST.
CONSiRUCTION LENDING AGENCY �T gq« vaRo Hwv pROP.LIN wioiH
I hereby affirm thnt ihara is a conahucllon lending agency for FppM ► '
the perfwmanca of�F�e work for which this permit is issued V.L.
�Sac.3097.Civ.C.i. 5�
P.L -
lender'�Nome +� �}
� Lender's Addrese P���F°°t Permii Fea � �OL'J v
� I certify thot 1 hove reod this applitption and atata that tha Isauonce Fee �� '�
ve information is conect.1 ogree lo camply with all Couniy ���es�iqation Fea �II^�O
ordinQnces and S�ata laws relating to building construcfion, Totol Fee J
and hqreby authorize representatives of thia Coun�y t--� .
upon t a6p;e �� na o f inspection pur es. ,
A � SEE REVERSE FOp E7(RANATORY LANGUAGE _
� �Signature of Applicant or Agent pa�� ��
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