HomeMy WebLinkAbout1479A 1NORKERS'COMPENSATION OECLARATION .
I hereby affirm ihol I hove o�e,,;F;�o,e o�co�sent to se11 qpp��CATION FOR BUILDING PERMIT �
insure,ar a cerufimte ot Wo�kers'CompensoNon Insuronce,
o�o ceriilied copy fhereof�Sec.3800,lab.C.) � '�� � COUNTY OF LOS ANGELES BUILDING AND SAFETY
voi�cyrlo. ' Compony
� Cenrfied copy�s hereby F�rnrshed. FOR APPLICANT TO FILL IN BWIDING 1J ����
ADORE55 —�
� Certified copy is filed with ihe counry bWld�ng inspec- BU4DiNG �
��on depo�tment. AD�RESS �325 [.SvNN �t�.CS�' C�'
Date Applicant CITY ���M41�� �iJ�{� ZIP ea-gt165 �ppq�ITY \�
CERTIFICATE OF E%EMPTION FROM WORKERS' NO.OF BioGS. L NEnaEST
COMPENSATION INSURANCE SIZE OF LOT NOW ON lOT O�N CROSS Si.
�This section need not be completed if the permit is for one ASSESSOR
hundred dollors(b100)or le5s.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
iEt. —If4� USE 20NE �P
I cenify�hoi in ihe performance of�he work fo�which�his ��'�'NER S V �ff NO. �1—G � � , a.
permil is issued,�shali no1 employ any person in any monner qDORESS Z�32�j �=`�NN 'ST �, SPECiAL 0
so as io become subject to the W rkers' mpensotion Lows. COhloinONS („�
aTY D a�cv.�N� g rl-tL- ZiP 9���r'� �
�ote��Appl kam O
� NOTICE TO APPLICANT: If, ofle akin his Certificote of /RCNi7ECT OR TEI. DiSIRKf GROUP TY7E FlRE PROCESSED BY V
EzBmplion, yoV ShOul(J beCOme SUbjeCt t0 Ihe WO�kerS' ENGINEER NO. ���T Z (� W
Comprnsa�ion provisions of Ihe La6or Code,you musl forth• AD�QE55 �Q �7L? n-
wiih comply wiih s�ch provisians ar Ihis permit shall be V7
TEI. � STATISTIG4L ClASSiFlCATIOM APT. CONDO. Z
deemed revoked. CONtaaCTOa N No. (��
LICENSED CONTRACTOR$DECIARAT�ON ��� ClASS NO._.pE�\_OwELI,UNtTS
I hereby affirm thot I om ticensed unde�p�ovisions of Chapter 9 nooaESi NO.
(commencing wiih Setlion 7000)of Division 3 0!�he Hosiness and ��� SEWER MAP
Pro(essions Code,ond my license is in full force and effecf. CITY CtqSS BK. �. YAIIDATION
SO.PT NO.Of ND.OF , CHEIX
Litense�d�mber �iC.C�OSS SIZE STORIES FAMIIIE$ ONE
❑ s qLl1ATl0�
CoMra[tor �- Dote DESCRIDTION OF WORK A� ❑ 1p
�I am e:emp�under Sec.
Q A't�a SL.f�-� � � �
n , AITER
B.BP.C.for this reaton r��1 � ��V�� REPAIR � S
Daie: u5e or �7�
EXISTING BLDG. R�SIOENC-L DEMOI ❑
Signoture APPUCANT TEL. FINAL
OWNER-Bl1IlDER DECIARATiON PRINT) NO. pATE�Z��
I hereby afiirrtt that I am e�empt from the Comroc�oi s License � -
Low for thr.following reasan(Secfion 7031.5.B�siness and aDORESS FINAL/
Pro essions Code): , FRE ENi BY (./�J c�� Q�.G F4 '
BUILOING
1, as owner of the praperty, or my employees wiih ADDRESS #� � �
wages as fheir sole compensolion,will do Iha work and ��q��TV , "
Ihe strutture is nol inlended or offered for sale(Seclion � • •6 8 G 0
70d4,Business and Professions CodeJ. MOVING . TEL.
� I,as owner oi the property,om extlusively coMrocfing CONTRACTOR NO. • • e b�,O O_
wi�h licensed conlraUars fo construtt the projetl(Sec- .. . �
lion 7044,Business and Professions Code�. ADDRESS
REOUiRED fOTAL SET9ACK D 9.0 9-8 8
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.IINE WIDTM
I hereby oHirm ihm�here is a construc�ion lending agenty for caONi �
Ihe performance of ihe work#or which this permil is isfued P.t. ,
(Sec.3097,Civ.C.). sioE
P.L.
Lender's Name
� LpMA Ref.N
P.C.Fee f Permil Fee
lender's Address
I certify tha�1 hava read this application and s�ate Ihot the �ssuon<a Fee , LDMA P/G M
o6ove informolion is torrett.I ogrea lo comp�y wilh oll Counly Invas��ga��on Fee
ordinances and Stata laws relating 10 building construclion, io�ol Fee IDMA Perm.M
and here6y au�horiza represe atives of this County to enter
upon Ihe above-m nlioned operty for inspeclion p�tposes. . . " , .
SEE REVERSE FOR EX�IANATORY IANGIIAGE
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