HomeMy WebLinkAbout1376A (13) i _ ....__ _ _ _ .
WORKERS'COMPENSAiION DECLARATION . � � - ��
I herBby affirm thaf I hQve o certifiwte of�a�=e�;,o 5e�f �� -- - --�-�-� APPLICATION �FOR BUILDING PERMIT �
irtiyire,or a certificate of Workers'Compensation Insurance,
o�a cenrfied copy ihereot(Sec.3800,tati.C)- " ' COUNTY OF LOS ANGELES BUIID{NG•AND SAF�TY
,
_.
� ❑ yNo. Company . . _ . . . .. . _ __.. -. . �
Polic
Cerrified mpy is hereby tum�sMad. . FOR APPLICAN7 TO FItL IN euuolNc 4 �
ADDRE55
� Certified copy is filed with tFe counry 6uilding inspeo- gU4DING �� � r- /� ,
lion deporlmeM. AppRESS L 3'Z �• �` /Z�-�J ✓k, . .
Qafe , . Applicanf � CtTY ���.t.��a �R � `}/76$ �pU,utr
� CERTIFICAFE OF EXEMPTlON PROM WORKERS•.�.- .. . ... � . .. . NO.OF BLDGS. � - NFAREST. ..� �` . � _. ._ .�_._ . : :
� � ••� � COMPENSATION INSURANCE 5¢e OF LOT wOW ON LOT CRO55 SL �
(This sedion need nW�be completed if tbe permit is 4w•.one •-� -�q- .. ASSESSOR � ;.. . ... - - .:.-._._. �
bundred dollors(;I00�or Iess.j . �� T��T BLOCK l0T NO. S J Mqp gppK : � �PAGE VARCEL
OWNER"
�l�.i� -�/irttl`'.+�—N`o.��� g,�'- use zon� n�av
i certify that in the performance of the work tor which this �p 1 NO. ' 1 Y
permit is issued,I aholl nof employ ony person in ony monner ����ry�, SVECIAL - -�- -
so os to become su6jen ro fhe Wor i Com� nmtion Lows. ADDRE`''S�2 25'�� �' ��-'-� ����� �� !���' �X+J CANDiTIONS Q
�� � , � �` ziP 9�z�aS .. u
Date�� � APPIicaM - CITV _ �CAn.9Q �
� ARCHITEGT OR � TEL.
NOTICE TO APPLICANT: if, offer aking lhis Certificate of DiSTR�CT GkOua TYPE FIRE PROCESSEp gy O
Exemption, you should 6awme ubjec�to he�Workers' �-�--�--
ENGINEER NO. �� CON57 Z '
Compensaflon provisiona of.the La r. � ou mus1.forth- qpDRESS . �a W
.._ .. _' _ . . 0.
with comply with sucb provisions or this permit stwp be .. . __. � "
dqemed.revoked. .. - . . . - . ,,- CONTRACfOR Q h.� T� -. . . . STATISTICALClA551PICATION , APf. . _
UCENSED CONTRACTORS DECiARATlON.---... . . . __ �K. �CLA55 NO.��D4VELL UNtTS_ _
I hereby offirm iMt I am licensed�nder provisions of Chopter 9 A�DRESS NO.
(commencing with Sectbn 7000)af Division 3 01 ihe Business and ...... l�C. ShwER MAP � . .. . .
Profeuiona Cade,and my license is in full force ond eMect C�tt CIASS - VALiDAiION � �
� . . . . - . .. SQ.FT NO.OF NO.OF CHECK BK. PG. � .
Litanse N�mber � �'��� � Lic.C(ass� � ���� ' SIZE � � �-STORIES �- -FqMIUES � ONE -
. . - . - Q . VQUATIQN.._...:._
� � DESCRIPf10N OF WORK �W OO . . . . .. ,
ConMactor� Dare � � s � .
�I am axampt under Sec. . . . . � �. . �aT��. ........ . AITER � �
........ .. ��. s . .
B.BP.C.for this reason �� _ . .. . .. .
oara: us�a
EXIST�NG 6LOG. �Ma ❑
Signa�u�e .. . ..... . • APPtIGnNt RVt-..... TEt.�7/'1C� �"' FINAL � . . . .
OWNER-BUILDER DECLARATION PRINT ��KL� E� NO. _DATE
I harabKa££rm ilwtlam.qwmpLfram the Cantrxtar�'s liconse - . .. .- ��. �
Law for ihe followin reason�Setiwo 7031.5,Bosmess and ADDRE55 �° .j2,$ �. �=n� � -- -� . � . z�,.,.
9 ( . . FINAL-`=`.� .
. .,._... .._ _ Y _ . .
�Rof ons Code�. ... . _.. ,.,. . E . ,. . . . 8 . ... .. ._. . . .. .
euaoir� �1 3 7.b A '
1, as owne�of the property or my employees with AppiE55 .
- wages os their sale compensatmn,will do ihe work and
ithe strudure is not intended ar offered for sale(Section ����TY ` � #�� � � �� . '
I�t 7044,Business and Rafeuions Code). n�pvuvG TE�. ^`1
i � I,os owner of the property,pm exclusivaly conlracting CONTRAC70R pp. X J . � • �4 9,2 S ,
� � witk�licansed controctors ro constrod the�projee�(Seo- qDoeess �� � �� !��Y � �� • •4 9.2 5 c=i
`; tion 7044,Business and Professions Code). � ,
\ -��� � CONSTRUCf10N LENDING'AGENCY �� " ..REpUIREO.. . yA� .MyY TDTP.l5ET6/� � �
ser ea« PROP.UNE WIDTH i 5,� _ . 0 Z 1 6—8 5
i.hereby affirm that ihere is a construction lending agency for pgp� �1 ..
� tYw perfwmance oi�he work for which 4his permil is issued �� P.�. : �
(Sec.3097,Civ.C.I. SIDE ..
. v.i.
^ Lender's Name �..- . - . ... . . � '- �,
m - P.0 Pee S . ..-. . Permi�Fee � ����IDMA Ref.8 � � -� :
= Lender's Address� � � ' ' � .
�
t cer7iiy lhot.l,hore read_thu_applicotion and slate.lhal the . .. . - Iss�o�ca Fee � :IDAM P2 k - - ' - -
� abpve information is carrect.I agree to comply with all Counry ���es�igation fee : �
W ordinanc s and State laws relating to.b�ilding construction, ;o�o��._ _..�'..� � � .��pMq parm,k� � � �� �
� - ...._. ......_.._......_....__.
� and her y authori e representaiives af this Co�nty to emer . . � -
� upon t bove-me �ioned propeny for inspec�ion purposes. �� _ � _
. ..... � . .. .____._.__... ._..... ..... ... .. . ' .
�'�� Q �(1G � SEE REVERfE POY EX►LANATORY UNGUAGE � - -
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