HomeMy WebLinkAbout1278A 2539A WORKERS'COMPENSATION DEClAR4TION �
I hereby affirm that t have a certificate of consant to self ����l������ ��� ���i ���� Be�pA'�
insure,or a certiiicale of Workers'Compensafion Insurance, i � r� ���
or a certified copy�he�eof(Sec.380D,Lab.C.) ' COUNTY aF LOS ANGELES BUILDING AND SAFETY
Policy No. Compony
� Cer�ified copy is hereby furmshed. FOR APPIICANT TO FILL IN A���u/1, 5
�
� Certified wpy is 4iled with Fhe county building inspec- g�ItDING � Q-' �
tion depurtment. ADDRE LOCALITY p�y�
NEAREST
Oate � Applicant CI7Y �1 IP CROSS S7.
CERTiFICATE OF EXEMPTION PRQM WORKERS' NO.OF BlDGS, A55ESSOR
�COMPENSATION INSURANCE SIZE OF lOT NOW ON LOT � MAP BOOK PAGE PpRCEL
(Thia section need nol be completed if the permit Is for one u5E Z NE nwP /�� j��/
hundrad dollars(5100)or loss.) iw,Ci etocK �ot nw. �j rro.
I certify that in the performance of the work for which this �WNER � !� NO. 'f��pp CON�DITIONS LL
permit is issued,I sholl nof employ any person in any man�er DIS7RICi GROUP TYiE FIRE ��`` D BY �
so oa tc 6acoma su6'en to the Work r'Com nsalion lnws. ADDRESS CONST /CR� U
� � � �� �o , iv �
Date�Applicant�� CITY I/ ZIP STAi15TIULCtA551FICATION APT. CONDO. O
NOTI('�TO APPIICANT: If,aNar maki this Certificate of ARCHITEQ OR � .TC�L,.
ENGINEER � - �� � C1P,55 NO.��WELL.UNITS�^ W
Exemption, you ahould become su6jett (o fhe Workers' . � a
Compensafion provisio�s of the Lq6or Code,you must forfh- - RE� . SEyyEp Mqp y
with comply with such prcvisions or �his permit shal! be �
deemed reroked. �pMpq�7pR �� ��' 8K, pG, VAUDATION
LICENSED CONTRACTORS DECLARATION lIC.
I hereby affirm ihat 1 am licensed under provisions of Chapter 9 ADDkE55 r NO. yp�UAT10N
(commencing with Section 7000)of Divisian 3 of fha&ninar ond LIG � � 2�.$R
Prof�uiotfs Code,and my licenae u in full farce nnd effect. UTY �f CIA55 t ��00 2 ,
� 5Q.FT. "��� �9 NO.OF NO.OF CHECK �
Licensm Number Lic.Cicsa S�ZE y-� STORIES FAMILIES ONE �i� � � �2`3
Contractor pa�e DESCRIPTION OF WORK ��� NEW � s I • •2 S O O
�1 om exempt under$ec. A� • � �2 5'Q C�
-{� ALiER � FINAL �/ / �j
B.&P.C.for this mawn � 7� REPniR � OATE��J fC]� O �1.L']�s(�
USE OF F4ZJ /�
Date: E%ISTING&DG. �a ❑ �
Signature '°'����`�T iE�.
OWNER-&IILDER DECLARATION ruiNi nro. �G
1 hereby aHirm that I am exampt fwm the Canrcacror's licenae qDDRE55� � !.w� !�1 �
Law for the follawing reason(Sec�ion 7031.5,Business and
�ions Code): PR ��
I, as ownm af the o y P y BUILDING
pr perty, or m em lo ee7 wilh AWRESS
wagea as their wla compenaation,will do fhe work and �� z 2�j,�,,9 F
the structure is noY intendad or oHered for sale(Secllon ��0`��TY
� 7044,Busineu and Profassions Code�. MOVwG �_ ie�. �_ u. .. . •�
I,as owner of the property,am exclviively COntrotling NtRAROR NO.
with licensed conhactors to conatruct�ha projec�(Sec- AWRE55 � � • •3 6 7 5
fian 7014,Busineas and Professions Code).
REqUIRED TpTAI SET&0.CK FROM EXIST. � � _
CONSTRUCf10N IENDING AGENCY S�gqp� YARD HWY p�p ��N WIDTH �3 �
I hareby affirm that there is o conatr�ction lending agency for FRONT
the performance of 1ha work for whith this permit is issued v.�. 0 Q 0 2—8 4
tSec.3097,Civ.C.). 1 SIDE . . .
�' P.L.
� lendei s Name / ,�../f
$ P.C.Fee S �3��'V Permif Fee
4nder's Addrass
� I certify Ihat I hnve read this opplitotion and state that the luuance Fee
� abova infwmation ie cwrett.I agree ro mmply with all County tr,ves��gaeon Pea + �
g ordinances and Sfate lawa relating ro building construction, Tam�F� ���
tY and he by authorize representaiives of this Co�nry to enter
� �pon 1 e o6ove-meMlo ed properry f inspection p�rpotes..
' SEE IIEVERSE FpN EXPLANATCYY UNGUAGE
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