HomeMy WebLinkAbout1707A 1708A (10) WORKERS'COMPENSATIDN DECIARATION �' ' � �
I he�e6y offi�m.thpt 1 hove a certificate of consenl io self qpp�ICA�'��N FQR BUILDING PERMiT
insura,or a certificote of Workeri Compensiion Insurance,or '
a cerrified copy ihereof(Sec.3800,lab.C.) COUNTY OF LOS ANGEIES 6UILDING AND SAFETY
Policy No. Company '
� Certified copy is hereby`turnished. FOR APPLICANT TO FILL IN Bu��owc, (� /1 /��
� ADDRESS p sIO (� �C�_
Certified cOpy is filed wiih the county building inspec- BUILDING /� � /
fion dapartmenf. ADORE55 `. LOCALITY �p iCLf.ff
NEAREST
Dote Applimnt CI7Y t f ZIP CROSS ST.
CERTIFICATE Of EXEMPTION FROM WORKERS' wo.oF BiWs. a55essoR
COMPENSATION INSURANCE 5¢E OF tOi� i7� � NOw ON�oi MAP BOOK paeE pqRCEL
(This section need not be completad if the permit is for one USE ONE MAP
TRACT BLOCK LOT NO, ' NO. Q }
hundred doilars(5100)or less.) . ,/ — �
TEt. SPECIAL a
I certify that in ihe performonce of the work for which this OWNER h t No. 6 -lu 2 3 �6�OOp CON�I7iON5 Q
ermif is issued,I sholl noi em lo an �iSTRICT GROUP TYPE FIRE PROCESSED BY
p p y y person in any manner qDDRESS � CONSi. 20NE �
sa as Io�ecopie subjecl to the Workers' mpensotion Laws. �a
/O
Da�e�/ �� � AppliWnl � CITY 21P STATIST�CALC�SSIFICATION � APT. CO� �
NOTICE TO APPLICANTr If, after aking �his Cer �at of - ARCHITECT Ok . TFL W
Exemption, you shoutd become wbject to the orkers' ENG�NEER NO. cLA55 NO. �0 oWELL.UNI75_ p,
Compensotion provisions oi the Labor Code,you must forth- � � I
AD�RE55 SEWERMAP Z' +
wifb comply wifh such proviaions or this permit shall be TE� �
deemed revoked. _ CONtenaai P � �,.1r�� No. y-?Z 2p BK �. VALIDATION �
�.� LICENSE�CONTRACTORSDECLARATION ��� 36�JYJ
"T hereby affirm ihat I am hcensed under provieions of Chapter 9 ADDRESS pL'��(/ .:�1 J fi' NO. YAtUAT10N
�commencing with$ec�ion�000)of Drvision 3 of tbe Business and -}-. ���
Professions Code,aru!my license is in fu41 force and effec�. aiv L •yy.b✓�1 CtA55 G'.z b ��Q, f�'T�
`'� i��.c�ass� SqEFT�p sTOR�s AMi�Es oNeK �1 7 Q 7 A
LicenseNumbe� ���J �
Controctor DESCRIPTION OF WORK /�
�_ \J New " a #•.•••2 3
^ • ^ OfC � 1 } AW � I �U�O
�rJ
� I om exempt fram the lice ing�equiremeMs os�om o },J � 2E'1 �d�� W P� • •
licensed archifect or a registered professional angineer ALTER � FINAI �� �� ��Q�O�
octing in my professional capacity (Section 7051, � DA7E � 3J
REPAIR
Business and Professions Code). USE OF p�IX � FINAL O�O�'8 2
EXISTING BLDG. BY y
Li[.or Reg.No. Dafe APPIICANT TEI.
- OWNER-BUILDER DECLARATION PRINT� ND. "
1 hereby affirm thar 1 am exempt from the Conrmctor's license .
Law for the follOwing rea5on(Section 703�.5, Business end A��RE55 �,,7 Q$A
Professions Code�: aRE eN -
BUIIDING
I, as owner of the property, or my employees wfth ADDRE55 �}�!�� �,�
wages as their sole compensation,wi�l do�he work and
the strutlure is naf intended or offered for sale(Settion IOCAUTY � ��2�5 Q
7044,Business ond Pro4essions CodeJ. MOVING TEL � � � . . -
� I,as owner of ihe properfy,am exclusively controcfing CONTRAC7pR NO. � • •!2,,5 O�t
with licensed mntractors to construct the project(Sec- qDDRESS
lion 7044,Business and Professions Code). Q�Q Z••8 2
REQUIRED 70iA1 SETBAIX FROM EXIST. �
CONSTRUCTION LENDING AGENCY �7 gq�K YARD HWV pROP.lWE WIDTH '
I hereby affirm that there is a construdion lending agency for FRONT
the performance of the wo�k for which this pe�mit is issued p_�
(Sec.3097,Civ.C.). SIOE �
P.L.
Lender's Name �/
� Lender's Address � P.C-Fee 5 ,�-f � Perm�i Fee ,/��
I certify ihot I have read this applico�ion and srote fha�ihe �sso ce Fee ���
iobove informofion is correct.I agree to comply with all County Invesr�goeon Pee ��
ordinances and State laws relating to 6uilding mnstruc�ion, �
� and hereby auihorize represenfatives of this County to enter Toiai fee ,-. � S
u
� opon fhe obo� -men�ion prOP �y for inspecti�on�urpas^es. . ,
� � /////J1 / �� SEE REYERSE FOR EXPtANATORY LANGUAGE � � +
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