HomeMy WebLinkAbout1586A (9) WORKERS'COMVENSATION DECLARATION �
insureboraacertifcateofWorkersrtCompensationglnsura g" APPLICATIOIV FOR BUiLDING PERMiT
or a certified copy rhereof(Sec.3800,La6.C.) COUNTY OF LOS ANGELES BU{LDING AND SAFETY
P�olicyNo. Company BUItDING (� (�
Cenified copy is hereby furniahed. FOR APPLICANT TO FILL IN qODRE55 d �
� Certified copy ii filed wilh iha tounty building inspoc• BUIIDING .�
tion department. A6DRE55 /� ✓J ►� LOC/+LITY
NfAREST
oore n����am an ^ m�r �/ z�v 6 crross sr.
CERTIFICATE OF EXEMPTlON FROM WORKERS' �'�g��� ��'�
. .. .COMPENSAStON INSURANCE � SIZE OF LOT NOW ON lOT hV�V 900K VAGE PARCEI
(ihis section need not be completed if the permit is for one TRAR 0 gtp�K L07 NO. U�Z� OP � "
hundred dollun(5100)or lass.) G I �f,,
I certi fhot in the erformance of tha work for wh� rhis owNER �Y No. 061^�/� CONon�ONS �
fy p DISTRIC7 GROUP iYPE FIRE PROCfSSED 6Y O
permit la{uuBd,1 shall n01 Bmplay any onon in an nner qODRE55 � � ��' / CONST, ZONE V
II �,a C n
w/�as to become s�jecl to the Wor er' m o� ws � � �� {0 ' O
,/pple(_�'�`�o� AppliCnfq CIN mQ Y� ZIP STAT�STiCALC1ASSIFKA �. CON00. F
ARCHITEROR L` , V r1^R . D CIASSNO.�DWELt.UNITS
w NOTICE TO APPLICANT: if. aflar making this Cenifkare NG� E R y� W
Exemption, you shouid become subjett to the Workers ,, -/ �'
Compensation previaions of the Lo6or Code,you must fahh- ADDRESS .�[.�.C�t�^���' �0 t/���� SEWFR MAP ��
with comply wilh such provisions or this permif iholl be �[] 7EL. VALIDATION �
daemed revoked. CONTRACfOR 4�` NO. BK. PG,
LICENSEU CONTRACTORS DECLARATION- uC.
I heraby affirm tFwt 1 am licer�sed u�de�povifioro of CVapTer 9 ADDRESS No. YAlU0.TlON �
' (commencin9 with Seclion 7000)of Division 3 of the Business and IIC. = 9�A1
' Professions Code,and my license is in full forca ond efFect. CITY CtASS / ti/ �
SQ,R, NO.OF NO.OF CHECK . ....
� ticenae Number L�C.CIasS SIZE STORIES FAMILIES ONE
�,,,�,a,�a, oa�e DFSCRIPTION OF WORK ct'�! C 0 v? NEW = z 1 5 8 6 A
( �
�I am exampt under Sec. ,e,�� � FINpI p #� �� � ��
B.&P.0 for this rwaon �PaR � DATE a 7 O� � • •3 6 7 5
USE OF FINAL �f • � ��b,7 S=
Oafe: EXISTINGBIDG. ��� � ���yC �
Siynq}Vre - APPLIG4NT TEL-
OWNER-BULLDER DECIARATION ��NT NO. O��Z 2-H 5
1 heraby affirm lhat 1 om exempt from the Controctor's Licanse pookf55 �
Law for ehe fol{owi�g reoson(Section 703I.5,Business o�d
Profee' s Code): P
6U�LD�NG
1, m ownar of the qoparry, o�my employeae wilh ADDRESS
wages as�heir sole compenaafion,will do�he wo�k and `���T,
the structuro is nat iNended er offared for sale(Section
7W4,Business and Rofessions Cade). A�/�NG TE�,
� I,as owner uf�ha property,am eaclusivaly co�trecting C NTRACTOR �•
with licansed coniracfors to mnaNuct the proiect(Ser qpDRE55
tion 7614,Business and Rofes�iane Code].
RE(�UtRED TOTAI SE7BACK FROM E%IST.
CONSTRUCTIDN LENDING AGENCY SET eACK YAR� HWv PROP.LIN WIDTH �
I heraby affirm ihat ihere is a canstructian lending agency tor ippryT
Ihe pa�formance of�he work for which this permit is issued P.�.
7Sea 3097.Civ.C.). SIDE
P.l.
_ Lenderb Nome - - ]�
P.C.fee{ - Permil Fge ��'V
lender's Addreu O S�
I cartify thot I hove read this applim�ion ond sloro ihat rhe iuuance Fee
obove informatian is wrred.I aqraa to wmply wiih all County Invesiigolion Fae �/'� ��
ordinances nnd Siate laws rela�ing�0 1lding tonsiroclion, To�al Pee (O
and h by outhorize exntat'e thre County to enter
upon t bova- m ne pro ty f inspactioo purpoees .. . ... . .... ..
�J_.�i7��� SEF YEVFlSE FOR E%►LANAiO11Y LANGUA6E � ` , - � - �'
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