HomeMy WebLinkAbout1489A (8) .�WORKER$'COM�ENSATION DECLARATION . „ f�
I�Fereby oflirm thaf 1 hava a teriificate of consenl fo self APPLICATI�iV FOR BUILDING PERMIT � �
��nsure,or o certificate of Workers'Compensation Insuronce, �J
or a ce�riFied copy the�eof�Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PoIlcyNo. Company
� Cerrified mpy is hereby furn�shed. FOR APPLICANT TO FILL IN eu��o�NG '/
ADDRESS �`)"�� (ytLa�
� Cerfified copy is filed with the counly building fnspec• • BViIDING o 1� c� JC
tion department. ADDRE55 z���u C, J � y��
Da1e � Applicont CRV � ZiP LOCAUTY
CERIIFICATE OF EXEMPTION FROM WORKERS' � i NO.OF BLDGS. NEAREST �t_� .
COMPENSATION INSURANCE SRE OF LOT B �/ NOW ON lOT CRO55 ST. i u�'/�'
(ihie se<tion need nol be completed if the permil Is for one TgACT `�ZS rS BIOCK LOT NO. .5� ASSESSOR
h�ndred dollars(SI00)or less.) MAP 900K 7AGE PAR[EL
iEt. USE�ONE �P
OWNER
I terlify ihol In ihe perfarmonta of the wo�k for whith�his � N07/5R— .n-/ S�`�,' pp � —
permit is issued,I sholl not emp�oy any person in ony monner ADDR�SS - ' !- � �ECIAL �
so a�10 become suhject fo tha Workeri Compensallon Lows. CONDITIONS �
U
ate Applitanl CI1Y ZiP �
ARCHITECT OR 7E1.
NOTI TO APPIICANT: If, afler m king this Certificote Of DISTRICT GROUP C NST. / � ZONE ��ESSED BY Q
E■emptton, you shov�d becom �bjact to rhe Worken' ENGINEER No. t �
Compensmlon provlsiens of the l or Code,you must Forth- qDDRE55 (� Lvd �� W
wHh comply with such provisions or Ihis permit shall be - p,�
deemed revoked. TE� TATISTICAL CtASSiFICA I N A7T, CONDO. �
CONTRACTOR NO_ n1 z
LICENSED CONTRACTORS DECL4RATION � �i�, MSS NO.�LDwFtL UNiTS
I hercby affirm�hat I om litensed under provisions of Chop�er9 ADDRE
(commenting wi�h Secrion 7000)of Division 3 of tha Businass and ���, ��R�P
Pro�eseions Code,and my license is In full forca ond effec�. CiTY , CtA55 BK � VILLIOATION
SO.FT. NO.OF NO.OP CHfCK
LicenSeNVmber lic.Clos7 SIZE STORIES FAMILIES ONE
�� VALU ION
Cantraclar pota OESCRIMION OF WORK A D s J 5M�
❑ V �
❑I am exempl�nder See. �
ALTER
B.BP.C.for fhis reason REPAIR ❑ s �1 4 8 9 A
Da�e: USE OF
EXISTING BLDG. ��a ❑ {I� � • • • �
Signalure APPLI(/�NT TEL FINAL
OWNER-BUIIDER DEGLARATION PRINT NO. DATE , � ' '4 9,2 5
I hereby affirm ihat 1 om e.emp�from tha Contractor's licanse � � � Q„
Law far ihe following reason(Section 7091.5,Business and ADDRESS FINAL � � �T U � 4 ,�5�,
Q.,�Pr ssions CodrJ: pp N 6y
au�io�Nc �2��/14�9� 0 9.0 9—8 8
I, as owner of�he property, or my employees wiih A�DRES$ /O
ages as their sole compensation,will do�he work and ��q��TY �
�he s�r�ctwe is not intended or ofiered for sale(Section �f /�
704a,Bvsiness and Professcons CodeJ. MOviNG iE�. - �7�,,,!w� �—��GID/��
� I,os owner of rhe propeny,am e.dusively conirading CONTanGTOR NO. v f�'��
with licensed comrocton�o conslrocl Ihe projett(Sec- qpOREu I�
rion 7044,Business and Proiessions Code).
CONSTRURION IENO�NG AGENCY - � SET BACK YARD HWY 1OiApROR UNE� WIOTH
�hereby affirm that thera is a construdion lending ogenty for ikONl �
the performance of the work for which this permit i�issued p.�,
($et.3097,Civ.C.). SIDE
P.L.
lendei s Nome
��'r� tDMA Ref.M �
9 lender's Address P.�.Fee S Permii iee +v �
a I certiFy tha�I hova read this applica�ion and sta�e thai the iseua�ce Fee 1�J�U �DMA PiC N
_ obova Information is corretL I agrea ro comply with oll Covnry invesugor�on Fae '/
ordinances and Stata laws rela�ing l0 6uilding construttion, Toiol Fee 7` �'�+S LDMA Perm.N
and hereby a�thorize represantatives of this Covnty to enter
� upon Ihe obove•mentioned properry far inspection purpoees.
_ f e� "" SEF REVERSE FOR EX�IANATORY IANGUAGE
�— iywm�e of Ap tim Aqenl pore