HomeMy WebLinkAbout1008A (5) WORNCRS'COMFENSATION DFCLARATION � � '
� ��,�h�o";,m rh�i I hr.v.o��,,;���a.��{�o�,��„o,��f , ..APPLI.CATION FOR BUILDING PERMIT �
��sure,or o cert�(�co��of LVerkers'Cnmpenso��on Ir.surance, ' '
or o ce�i�Ged cony�he�eoi�Sec.??00,lab.C.) _ : ' COUNTY,OF LOS ANGELES 6UILDING AND SAFETY
Po❑IlcyNo. Compony .. i - � �. • • ..�. ., • - .
CeniFirtd tcpy�s hereby�urnished. , FOR APPLICANT TO FILL IN,._• eu�iatie p�O �
� . .... ti no�a[55 p
Cer�lf�ed copy is(�Ied w�ih ihe couniy build�nq ins�ec- gU�l��vG
��on depo.imeni. n7CSES5 �. �.�
Do�e Appllconr CifY '/n I��_ 2iP y�-/(�% ip�quTv
�,f.uin.
CERT�FICAiE OF EXEA!PTION FROM WO4KER5' ' � .sti -•�+�0.O�Bf�GS' � � � + NJ�PE51
CON'•PFNSATIOY INSURANCE 512E�C�LOT NOW CN LOi� �4055 ST. y�lL
(This sec�ion nr.ed nof be.compleled if ihr.permii is for one n55F550e
hu�dred dollan�5�001 or les:.) TRACT BIOCK l0T NO. ��+pP gppC OAGE PARCFL
nio. -fe/2 usE zo!�e rraP � �-
1 ceri�ly rhat in ihr,perfo�mance at ihe wo�k for which ih�s OwnER L r�o. a'
permi�is issucd,1 shall nol e!m�loy eny person in ony monner pDC4E55 SPECiAI �
so as�o become subjr.ct to ihn Wo�keri Compensoi�on Lows. CO':`JITICN$ V
� Da�� A�plicanl CITY ZI^ �� �
NOTICE TO APPIICANT: If, nOcr moking Ihis Certlfica�e o1 AR�HITECT OR TEL. UiSIR:Cf GaOu? 1VVE FiAE �'ROCESS[D BY �-
Exem lion, � fnG'NFE4 h0. � ^ COhST.� ZONE �.I� U
p you should become sub�cct to �he Wo�kers'
Compensation provisions of Ihr.labor Code,you must forlh• nD^�fSS K3 TS d
with comply wilh such provisio�s o� this p�rr�it shnll be TFI. N
dCemed revOked. �y/a�y� � � STA715TIG4L QASS�FICATION A?T. CO�DO. Z
COVTRACIOR VW��.a�/V NO.
LICENSED CONTRACTORS DECLARATION ���. C1A55 NO.��DNTLL.UhITS_
I hc�eby a�firm�hot I om licr.nsed u�der prov�sio�s af Chapler 9 aDDRESi Np
(commencinq wiih Sechon 7000)o(Oivision 3 of fhe Buslness ond �i� ��R l��P
Proless�ons Codc,and my Ii[P.�SP i5 ill IuII�O�CC O�d P.Iff![1. [ITY CLA55 �� � VALIDATION
50.FT. '`'^� NO.CF NO.OF CHECK
Licr.nsc Num6e� lic,Closs SIZE W STORIES FnM�liES I �h'F
VALUATION
Con�rot�o� Da�e �FXR!PTi040F VJO4K � �Q NEW � '�. M
s ��.r
/. /. AC�
�I am eaempt under Sec 1 f7� .� (J, a �: � !�i%'?i'
A17E4 �p�
B.BP.C.(or�h�s reason (,� � qEpq�2 � S •• + • • • � �
Date: �� �F n �1 �� �
E%ISiI+1G BLDG r'�� ,n��'T If DEM1"Ol ❑ � p ti V.._—
Signoturc APiqI�,4Ni TEL. F{NAL p °„". . "
O\VkER�6UlICER DECLARATION (PR!NT� n"���'����� DAT � � �
c'��,b C�r. ii i; 1 —
1 hereby offirrtt�ho�1 om ezempt(rom ihr.ContmUoi s licen�e ACpaF55 .3 FINA�L
law l0�Ihe!f011owing reason�Seclion 7091.5,Dus�ness nnd �
Prciessicns fode)� �aE,c.i BY��
� eu:ic�:�
I, as owner of Ihe properiy, or my employrses wflh ACDc[SS
wa�es as their sole tompensa�ion,will do ihe work cnd �
the s!rucfurr.i:nol�niended o�o(ferr,d fo�sole�Secrion ��CALITY
7044,Aus�ness and Profess�ons Ccde}. n�.Ov�NG TEi.
� I,as owner of Ihe propr.rly,am rzclus�re�y coniracling CONTRACT07 NO
with licensed controctors to construU�he prolecl(Seo- aDC4E5S
tion 7044,Business and Professions Cadc).
CONSTRUCTION LENDING AGENCY SEi BACO YARD HWY �U�ApRO�I�NE� • W�Di1/
I herr.by affirm that�here is a consiruciion lending ogenty�or �ke.��
ihe pe.(o�mancr.oi�he work for which this perm�i�e issued r t.
�Sec.3097,Civ.C.J. S�OE
P.L.
lenAer's Name �
LD'AA Ref.p
Lender's Address P����Pe S Dermii Fee i
� I cer��ly�ho�i have.read this opplimiion ond s�ate�ho�the issoonce fee � IDMA P/C N ,
' above informol�on is correcf.I agree to comply w;�h oll County in�rsr�go��o�Fee l,.,/Tl
`� ordinances and 5!a�e laws relnting fo bu��d�ng construcfion, Taiol F�e � �,!`� LD�M Perm.M
ond hereby authorize represen�alives of ihis County�o enler
upon Ih/r�obovr.-men�ionr.d property for inspection vrposes.
A � 1 ��� ���� SFE RFVERfE fOR E%PLI1NAiONY IANGUAGE
4��
S�9nnW f Applicanl or A�Pnt p�
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