HomeMy WebLinkAbout1199A 1 WORKERS'COMPENSATION DECIARATION ��k
� insureby�roafCp1iica�eolWorkers'1Companso�onlnsurancef \ APPLICATION FOR BUILDING PERMIT �]
m a certLif/ied coupy�hereoi(Sec.3800,Lo6.C.J COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policp�d,s'�7 Company '� `�
� Cenifled topy is hereby iurn�sked. =2�� FOR APPLICANT TO FILL IN ADDRE55 �3S 7Q ,� L
.r.l- Cerfified capy is filed wilh 1he cooNy building inspeo BUitDiNG L (/ �
U fipn depo��ment. ADDRESS � J !� • `
Dofg�� /R� Appliton �T C�iY Lo I LOCAutY �
CE IFICATE OF E%EMPTIO ROM WORKERS' ND.OF BtDGS. J �qp�55T.
COMPENSATION INSURANCE . 512E OF lOT NOW ON t07
(This seclion need ne1 6e mmpleted if iha permit Is for one , n55E550R
huadred dollars(SI00�or less.) � TRACT BIOCK LOE NO. MAP BOOK DAGE PARCEL
pWNER , cl�c�vanr NO. O�� ��.? USE ZONE �P
I certify�ho��in the periormance of ihe work for which�his �' y.
permi�is issued,I sholl not employ any person in ony manner {,/D SaEGaI iy�.
so as lo become subject lo the Workers'COmpen5oti0n(.aw3. ADDRE55�.35/ • CON�ITIONS �
CITY 0.7 ZIP /��-5 U
Date ' � A lican� � �
NOTICE TO APPLICANT:�f, afle� moking this Certificote of AR�HITECT OR TEL. � DISTRtCT GROUP ttPE FiRE �ROCESSED BY O
ENGWEFR NO. - CON�ST.1----- ZONE I-'
Ezemp�ion, you should become subjecl to tha Workers' R - ���� , �[`� U
Compensa�ion provisions of tbe labor Code,you mus�forth- pppREu �V v"' � `'� p�,
wi�h compty with such provisions or this permit sholl be n TE�. p STATISTIGAL ClA55iPICATION AP7. CON00. (N
deemed rovaked. CONTRACT W.NO. 7� 7Z Z
LICENSEO CONTRACTORS DECLARATION �,�. 3$ yg 0.A55 NO.��µ'Fll.UNtTS
I hneby aNirm�ho�I am licensed undr.r provisions oi Chopter 9 AOORE55 / A.[+�n�O. ��R�P
(commencing wiih$edion 7000)ol Divislon 3 of the Business and �n� LiC.
Proleeeions Code,and my license ie in(ull force and effeU. CiTY O l!e•. ttASS � BK p� VALIDA?ION
�+ Q SO.FT9 NO.OF NO.OF CHECK
Licensa Namber-�O���� L(c.Class�� ' SIZE il3 STORIES FAMItiES ONE VALUATION iZ�00
11 p,, � ����O1e LZ DESCRIMION OF WORK N� � S
C❑onlrotlo���Q� f,f. ADD � ,
I am empl onder Sec.�� '3� qtiER
8.8P,C.for this reaeon ��' REPAW s
USE OF � �
Dafe: EXISTING BLDG. DEMOI
Si nOturE � A7PlICANT ' TE�• FINAL
9 OWNER-BVILDER DECIARAT10N PR�� � N�� '�� DATE jZ�-�
I hereby afiirm that 1 am exemp�(rom the Controc�or's License qp0aES5 -�3 w N/� /) C�ONT. FINAL
law(or�he follawing reason(Sedion 7031.5,Business and
Profesaione CodeJ: - - N . �y
❑ BUrtDING . �� � 9,9 A
1, a+owner of the property, or my empioyees wiih nDDRESS
woges as thelr sola mmpensarion,will do the work and � �� �
�he str�clure i�no�Intended or aflered fa�sale(Seclion ��`��TY � ' ' ' �
70<d,B�sinefs ond Professions Code�. � � � MOViNG � TE�-
� I,as owner af Iha properly,om e.clusively controcting CONTRACTOR NO. � • �3(�'��j
wirh licensed comracto.s io consrruct the project(Sec- qooaESS-- '
�ion 70A4,Bos�ness and Professions Code). • " •�L Il"�'
RE�111RED yqRD HWY i01i11 SET3ACR F �
CONSTRUCTION IENDiNG AGENCY sEr enCK PROP.lWE wiorti O E 2 6—H b
1 hereby offirm that�here�s o constrociion lending agency far fRON�
I tha pe�formance oF�ha work 1or which this permit is issued 7.L. � � -
(Sec.3D97,Civ.C.). 9oE
P.l.
lender's Noma
(�N lDM4 Ref.M
m P.�.Fee f Permil Fee dJ - '
� �e�de,•s ndd.ess
� I certify ihat I hove reod this opplicaiion ond slote thol Ihe � Issuonca Fee la .S o LDMA P/C N
above information is corracf.I ag�ea ta comply with all County �mesr�gauon Fee t-
S ordinance7 vnd Slate lawt�elaling to building mnslruttion, . To�ol Fee U �� IDMA Perm.R
ond hereby au�horize representa�ives of this Counry to enter'
� �po�the obove-men�ianed property for inspettion pvrposes.
M1 ��,����y� Z �� SFF RFVERSE FOR E%RANATOMY IAHGUAGE
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