HomeMy WebLinkAbout1306A (7) WORKERS'COMPENSAiION DECIARATION
� I hereby affirm iha�I have a ceriificate oF tonsent�o self APPLICATION FQR BUILDI NG PERMIT
ir�ure,or a cer�ificate of Workers'Compensouon Insurance,
or a cerflfied copy�hereof�Sec.3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
P�olicyNo. Company ^
av v FOR APPLICANT TO FIIL IN ADDRESS Z 3 I.r �� -
Cer�ified co ie hereb furnished.
� Cerlified copy ie filed with th"e tounty bvilding Inspec• BU4DING /�_��t ' � r'
Ilon department. ADDRE55 T' J 6�
Date Applicant CITv O ZiP � IOCAIITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. NEAREST .
COMPENSAIION INSURANCE SIZE OF lOT NOW ON lOi CRO55 5T. � �
(This saClion need nol be tompleted iF Ihe permif fs for one TRACT G,I BLOCK LOT NO. � ASSESSOR �
h�ndied dollors(E100)or less.) _ N✓+P�� PAGE PARCEL
�. �OG ���a� �P �� -�y
I cenify that In the performance of the work(or which lhis ownER / O. �
permit is issvad,I:hcll no1 employ any person in ony nner ADDRE55 SVECiA� �
so as lo hecame s�bject to tha Workar3 mpensa' lews. CONOITIONS �
xData--��� � ~��PP�icont CITY_ ZiP �
NOTICE TO APPLICANT: Ii, after m king this ertificate of ARCHRER OR--�f TFL �� DISTRICT GROUP NPE fIRE PROCESSED BY O
ENGINFER NO. ONS ZONE I—
E.emption, you should 6ocome subject to the Workers' � l V
Compensatian provisions of the lobor Code,you must lorth• qDDRE55 ` J W
wi�h comply with such provis�ons or this permil shall 6e . 7E ,_li�. STnT�STiCALQn55�Fl�nON aPT. ON00. �
deemed rovoked. coNTRACiOR N . 7'�1��
Z
LICENSED CONTRACTORS DECLARATION �� , C1A55 NO. '� DWELL.UNITS �
�� I hereby ofTirm ihot I am litensed under provisions of Chapte�9 ADDRE55 NO.
(commencing with Settion 7000)oi Divisio�3 of tha Busineu and . ��� SEWER MAv
i Professions Code,and my license is in full force ond eHect. CITY MSS BK � VAIIDATION
I ' S0.FT. NO.OF NO.Of CHECK
License Number Lic.Class SiZE �a2 STORIES FAMitIES ONE
�'� � � VAIUATION
I Controttor Dale DESGRIPTIONOF WORK " N� ❑ s r1 !�
-Gfi Q� ADD � �G '
i �I em ezempt under Sec. �l.rib
i AITER . • •
� �13Q6A
8.8P.C.for thie reoson � REPAtR f
USE OF � � n• • �
Dafe: E%ISTING BLDG. DEMOI �
$ignatore � APPIICANT TEI. � � • ��1 J,�0
FRINT NO. FINAL
OWNER•BUILDER DECLARATION DATE
-I herebyaffirm that 1 am ezempl from the Contmt�or's License A�DRE55 � ' '��a�'�l�
Law for the follawing reoson(Sectlon 7031.5, 8usiness and FINAL , �
I P�fessions Code): � Pk N 6Y Q 9,�� —�=•�
BU�LDING '
I, as owner of�he propeny, or my employees wi�h aoDBE55
wage�as their sole compensotion,will do the work and ,
the sfructure i�not iniended or atiered for sale(Section ��`��T�
7D44,Business and Professions Code). MOVING TFL. �
� I,os owner of ihe prope�fy,om eMclusively contracting �ONTRnCiOR NO.
wiih licensed contracrorz to constru�t tha projett(Sec• qo0RE55
tion 70a4,8usiness and Professions Code).
CONSTRLICTION IENDING AGENCY SEQBnCK YARD HWY T���'p�p��NEF wiDTH
I hereby afiirm�hat ihere is a consvut�ion lending ogency for FRONT �
the pmformance of the work for whith Ihts permit is issued v.l.
(Sec.3097,Civ.C.). SiDE
P.l.
lender's Nome
3�'`� IDhM Ref.N
P.C.Fee f Fermi�Fee V �
tender's Address
� I tertify that I hava read Ihis applicaiion and 5tate thot Ihe lauance Fee �U � tDAAA P/C N
_ above intormarion is correct.I agrea to comply wi�h all Counry ����s��go�bn Fee +� _
ordinonces and Slate laws relaring fo building consl�ucllon, Totol Fee d��� LDMA Pe.m.N
� ond her t i=e representatives of thfs County to enter
� uporyf{ie e-manlione pfrtyfor' spetti�p�rpose5.
� SFE RFVERSE FOR EX�LANATORY LANGUAGE
S�gnature of APPI�<an�or Ageni Do�e
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