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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�� �� N � N,�Ii��t. r. � X���1�� L� v^yN.c ,�.G.4f� UUy"• C"[�L• o ' mc Or v � �'� e�,�, om L �o 'e.o'� �G`''ti �h��.o 3 °o m .��'�'` � ,n �"� �� - �hx � cw �uy.�� cto �1A���.�-^.�.� d ^ c � � � p .. � a, n ,"��,'' `+.,w n, c"� �u .; r � o o — n -',�. 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