HomeMy WebLinkAbout1586A WORKERS'COMVENSATION DfCU1RAT10N �
I hereby affirm that I have a certificate of tonsent to self APPLICATIOIV FOR BUILDING PERMiT
insure,or a certificafe of Workers'Compensation Insurance,
vr a certified copy rhereof(Sec.3800,La6.C.) COUNTY OF LOS ANGELES BU{LDING AND SAFETY
P�olicyNo. Company BUItDING [� (�
Cenified copy is hereby furnished. FOR APPLICANT TO FILL IN qDDRE55 d �
� Certified copy is filed wilh iha tounty building inspoc• BUIIDING .�
tion department. ADDRESS '� � h LOU+LITY
NFAREST
oae ,���am an ^ m�r � ziv 6 caoss sr.
�RTIFICATE OF EXEMPTlON FROM WORKERS' �'�8��� ��'�
. .. .�OMPENSAT{ON INSURANCE � SIZE OF LOT NOW ON l0T hV�V 900K VAGE PARCEI
(ihis section need not be completed if the permit is for one T�R 0 g�p�K L07 NO. U�Z� OP � "
hundred dollurs(5100)or leas.) G I �f,,
I certi that in the arformance of the work for wh' this OwNER `Qf NO. O�+I^�/� CONDfI�ONS �
fy p DISTRIC7 GROUP iYPE FIRE PROCf55E�BY O
permit{a{uuBd,1 shall n01 Bmplay any onon in an nner qODRE55 � � ��' / CONST, ZONE V
w/�as to become s�jecl to the Wor er' m o� ws „ � � hp {0 FY
,/pp�e�_�`_�� ApP�iCOfq AROIITEROma� r� ZIP -( �� STAT�STiCALC1ASSIFKA • /�. CON00. v
V NOTICE TO APPLICANT: If, aftar moking this Cenifkare NG� E R tr'� 0 y�Df�"� . b CIaSStro.�DWELt.UN�TS �++
Exemption, you shouid become subjett to the Workers h�- -�- �{.� a
Compensation previaions o4 the La6or Code,you must fohh- qDDRE55 .A�.�Y'�/�'�` �0 1/�"7�0� SEWER MAP ��
with comply wirh such provisions or this permif iholl be �Q 7EL. VALIDATION �
daemed revoked. CONTRACfOR 4�` NO. �K' �''
LICENSEU CONTRACTORS DECLARATION- uC.
�� I heraby affirm that 1 am licensed unde�povifioro of CVapTer 9 aooRESS �. YAlU4TlON �
(oommancinq with Seclion 7000)of Division 3 ot the Business and IIC.
' Professions Code,and my licensa is in full fwca and efFect. CITY CtASS S �� �
SQ,R, NO.OF NO.OF CHECK . ....
� licenae Number L�C.CIasS SIZE STORIES FAMILIES ONE
cA�vona, pa�e DFSCRIPTION OF WORK ct'E! C 0 v� NEW s z 1 5 8 6 A
aoo
�I am ezempt under Sec. � FINpI #� �� � ��
�� DATE a 7 e�,� � � �
8.&P.0 for this rwaon �aaa ❑ 3 6 7 5
USE OF FINAL �f • • •�6,']S=
Oafe: EXISTING BIW. ��� � �l��C �
Siynq}Vre - APPlIG4NT TEL-
OWNER-BUIIDER DEQARATION ��NT NO. O��Z 2-H 5
1 hereby affirm lhat 1 am exempt from the Controctor's Licanse qooRE55 �
taw for the followi�g reoson(Section 703I.5,8usiness ond
9rofee' s Code): P
6U�lD�NG
V, m ownar of tMe properry, o�my employeae wilh ADDRESS
wages as�heir sole compenaafion,will do the wo�k and
the structuca is nat inlended or offared for sale(Section ��`��N
7W4,Business and Rofeuions Cade). A�/�NG TE�.
� I,as owner of�he property,am ezclusivoly coatrectiag C NTRACTOR �•
with licansed coniradors fo mnaNucf the proiect(Ser qpDRE55
tion 7614,Business ond Rofes�iane Code].
RE4X1tRED TOTAI SE7BACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET eACK YAR� HWv PROP.LIN WIDTH �
I heraby affirm ihat ihere is a constructian lending ag�ncy tor iRpidT
Ihe pa�formanca of�he work for which this permit is issued P.�.
(Sec.3097.Civ.C.). SIDE
P.l.
_ Lenderb Nome - - ]�
P.C.fee{ - Permii Fge ��'V
lender's Address 0 S�
I cartify thot I hove read this applim�ion ond sloro ihat the iuuance Fee
obove information is wrred.I agraa to wmply wiih all County Invesliyolian Fae �/'� �j (�
ordinances ond S�a�e Iews rela�ing�o ilding tonatroclion, To�al Pee (O / �7
and h by outhorize exntat'e thm County to enter
upon t bova- nY ne pro ty f iaspactioa purpoeei -� .. . ... . .... ..
�J��il�C_/ SEF YEVFlSE FOR E%►LANAiO11Y LANGUA6E - ` , - � - �'
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� SigrwNro of Appliwnr or Aqent Dote - .
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