HomeMy WebLinkAbout1582A (9) WORKEFS COMPFNSAT�ON DECLARATION
I here6y affirm rhat I hcve a�ertificote of consent�o seH �PPLwCATi0�1! ��R �UILDING PERMiT �
insure,or n ce�hhcote of Workers'Cnmpensation Insurance, �
o�o cerrfied mpy therPof(Sec.3800,l.ab.C.) CQUNTY OF LOS ANGELE$ BUILDING ANQ SAFETY
Poli<y No. �Company
� Ce�r�f�ed�oPy is hereby f�.�ished. FOR APPLICANT TO FILL IN euuoiNc '� s �� �i,�„�j�
ADDRE55 Z �J"'�(
� Cerfified copy is filed wifh�he county bui�ding inspec� BUILDING � r� �1,���� n„�1.
lion department. AD�RE55 a ��� �.•�� ��_ _
Do�e AQplicanl CITv '1 d� ��n+ ZIP L IOCAIITY .,y� -�[!' � �
CERTIFICATE Of EXEMPTION FROM WORKERS' NO.OF BLDGS. NEARESi ,
COMPENSATION WSURANCE SiZE OF LOi NOw ON�OT CRO55 5i. ���y.- .,.,��- .� -L..�r- .,.:3
(This section need no�be compleled it the permit is for one �ESSOR '
hundred dollars(5100)or less.) TRACi BLOIX l07 NO. MAP BOOK PAGE PAR EL
TEL p r USE ZONE MAF �,
OWNER
I certify that in the performance of the work for which ihis 0 � NO D v ""Z D NO. �,,,
permif is issued,�sholl not employ any persan in ony manner -f /�/p (����� � .,..� SPEGAL �
so as to become subjeci to the Worke Co p lion Laws. P.DDRf55 �/�-1 L D �(7+l�w� � ' CONDI710N5
� �� (��[ �aw �.�,r,t.q�w-� arv (It-µeu�9 �M�- na �l t1 p.
Dafe ~—.K-s-=s-�Applicont ARCHITECTOR TEL.
NOTICE TO APPIICANT: If, ofter making this Certificote of DIS7RICT GROUP TYPE FIRE PROCESSED BY 6�
ENGINEER N0. CONSY. ���� ZONE �
Exemp�ion, yoo shauld become subject to the Workers' $' i
Compensation provisions of fhe Labor Code,you musf forth- qDDRE55 (,..� '� � .-�v^s.G N
wi�h comply wilh such provisions or ihis permit sha11 be p�� ,C � TEL STA7IS71CAL ClASSIFICA7ION PT. CONDO. Z
deemedrevoked. CONTRACTOR ���+ G �-�+V NO. Zi '� �� f -'
IICENSED CONTRACTORS DECLARATION �6.�. _�•, n uC. �� ,� CLa55 NO.___c��_DWEu.UNIiS
I hereby affirm that i am licensed onder pravisians of Chapter 9 ADDRE55 �� ���I`� q`� �G�� NO.� �� SEWER MAP
�commencing wilh Section 7000)of Division 3 of ihe Business and O`AON h. ���� e-Y�� VALIDATION
.Professions Gode,and my license is m fuli force and effett CITY I'�� CU155 BK �
Q �f _ 50.FT-f NO.OF NO.OF CHECK
LicenSeNumber • v Lic.Class� SIZE F�� STORIES FAMIUES ONE
/ [J��(/ �`�u0� VAWATION
' Contracror��� �6��� ��' D V DESCRIPTiON OF WORK NEW ❑ s ���� (�Q
Date a /
w � �t�� a 5/ ADD
�I om exempt under Sec. �� ALTER �
B.&P.C.for ihi5 reason REPAIR � S
� -Date: USE OF DEMOL �
EXISiING BLDG.
Signature '4PP`pRINN) NO. FINAL /� �
OWNER-BUILDER�ECLARATION �Ah ��t'
I he�e6y offirrti that I am exempt from the Contrpctor's License
Low for the following reason(Sedion 7031.5,Business and AODRESS FiNAi•� -^.j r�Q G i�'
Professions Code�: PRE EN g1'
� BUILDING �: i. +� a :• a
I, as owner of Ihe property, or my employees wirh ADDRE55
waoes ns the�•scle cvmre.^.sa!ion,vr;!do i��e work ond A R
fhe struciure is not intended or of£ered for sole�Section ���A��TY , � � �J`°`)(�
7044,Business and Professions Code�. MOVWG TEL . ,� ,� n(����'�?;
� I,as owner of ihe ro ert dm exclusivel controcfin CONTRACTOR NO.
P P Y, Y 9 C>�,�I .�)"'..Li�
wilh licen5ed contractors to consiruc7 Ihe proiect(Sec- qDORESS
tion 704d,8usiness and Piofessions Code�.
CONSTRUCTION LENDING AGENCY SET�BACK YARD HWY T�TApROP.IINE R WIDTH
I hereby offirm tha�there is a construcfion lending agency for FRON7
�he performance of Ihe work for which this permit is issued P.L.
(Sec 3097,Civ.C.). SIDE
P.l.
Lender's Name �5-� ,�,..g"� tDMA Ref.R
P.C.Fee$ Permit Fee .�d :o L�' ►
Lender's Address
I cert�fy that I have read this applimfion and sime fhat the issuance Fee ��• � LDMA P/C X
above infarmotion is corred.I agree ro romply wilh all County Invesligation Fee
ordinances ond Slate laws relaling fo 6uilding construction, Tolol Fee �� 3� LDMA Pa.m.N
and here6y out rize representatives of this Coun�y to enter
upon e abov - en�ioned properly for inspection purposes.
�G/.tN .J�IrIJET/� �' f� SEE REVERSF FOR EXPIANATORY IANGUAGE
$igno�ure al Appli<on�or Agent �ote
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