HomeMy WebLinkAbout1199A (6) 1 WORKERS'COMPENSATION DECIARATION ��k
� insureby�roafCp1iica�eolWorkers'1Companso�onlnsurancef \ APPLICATION FOR BUILDING PERMIT `�
oi a certLif�ied coupy�hereoi(Sec.3800,Lo6.C.J COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic�d,s'�7 Company '�
� Cer�ified copy is hereby iurn�shed. '-Z�' FOR APPLICANT TO FILL IN ADDRESS �3s Q ,� L
.r.l- Cerfified capy is filed wilh�he counry building inspeo BuaDiNG L (/ �
U fion deporlment. ADDRESS � c7 !� • `
ooi����Applimn � an no J iocr,urv �
CE IFICATE OF E%EMPTIO ROM WORKERS' NO.OF BtDGS. J �qp�55T.
COMPENSATION INSURANCE . 512E OF lOT NOW ON LOi
(This seclion need ne1 6e mmpleted if iha permit Is for one , ASSESSOR
hundred dollars E1�0)or leis.) � TRACT 9lOCK LOT NO. MAP BOOK DAGE PARCEL
� ' �E�' ��pp ��� USE ZONE �P
I certify�ho��in the periormance of ihe work for which�his ��ER <t�QlLan. No. r.�p. }
permi�is issued,I sholl not employ any person in ony manner {,/D SaEGaI iy�.
so as lo become subjecf lo the Workers'COmpen5oti0n(.aws. NDDRE55�.35/ • CON�ITIONS 0
CITY �7 ZIP I��-S U
Date ' � ApplicoM � ARCHITECT OR TEI. , oIARtCT GROVP TYPf FIRE DROCESSED BY O
NOTICE TO APPLiCANT: If, afln moking this Certificoie oi ENGWEFR �� NO. - CON�ST.}----- ZONE I--
Ezemp�ion, you should become subject to tha Workers' R ���� + `-��`` U
Compensa�ion provisions of the labor Code,you mus�forth- qDORESS �V "'- � � ` p�,
winc �ompty with such provisions ar this permit shall be n TEL p STATISTIGAL ClA55ifICATION Avi. COrvDO. cq
deemed rovaked. CONTRACT W.NO. 7� 7Z Z
LICENSEO CONTRACTORS DECLARATION �,�. 3$ yg 0.AS5 NO.��µ'FlL UNtTS
I he�eby aHirm�hor I am Ifcrosed under provisions oi Chapter 9 AOORE55 / /Lt+�n�0. ��R�p
(commencing wiih$eUion 7000)oi Division 3 of the Business and �n� LiC. C r2 VALIDA?ION
Proleeeions Code,ond my IicenSe ie in(ull forte and effeU. CITV O l.�•. CUSS � BK pG
?,¢ f� Q SO.FT9 NO.OF NO.OF CHECK
Licensa Number-J u�r�/ L(c.C�ass�� � SIZE il3 SiOR1E5 FAMItiES ONE VALUATION��00
p� ZZ, pE$CRIOTION OF WORK N� �
Comrotlor 'Date �, ADD � S , .
�I am empl onder Sec. '3� qtiER �
B.BP.C.for�his reaeon ��' REPAW s
USE OF � �
Dats: EXISTING BLDG. DEMOI
Si noture � AvaiCANT ' TE�• FINAL
9 OWNER-BVILDER DfCtARATION PR��'�T N NO. �� pATE IZ��,
I hereby afiirm that I am ezemp�(rom the Contrac�or's License qp0aES5 -�3 w N/� /) CT ONT. FINAL
Lew(or the following reason(Sedian 7031.5,Business and
Profesaione CodeJ: - - N . �y
❑ BUrtDING . �1 1 (�,(�A
I, ae owner of the property, or my empioyees wilh ApDRE55
woges as thelr sole compensarlon,will do the work and , �� �
�he strocfure ie no�In�ended or aflered fa�sale(Seclion ��`��T� � • • •�
70<d,B�sinefs ond Professions Code�. � � � MOVING � TE�-
� I,as owner af Iha properly,om e.clusively controcting CONTRACTOR NO. � . •�j(j�]j
wirh licensed comracto.s io consrruct the project(Sec- qooaESS-- "
�ion 70A4,Bos�ness and Professions Code). ' " '�L �"�'
RE�l1�RED 101A1 SEi3ACK F i
CONSTRUCTION IENDiNG AGENCY SET BA�K �ARD Hvn PROP.lWE wiorri O E 2 6—a b
1 hereby offirm that Ihere rs o constrociion lending agency far FRONf
I the periormance oF Iha work ior which this permit is issued D.L. � � -
(Sec.3D97,Civ.C.). SioE
I P.l.
lender's Noma
(�N lDM4 Ref.M
m P.G Fee S Permil Fee dr� - '
� �e�de,•s ndd.ess
� I certify That I hore reod Ihis opplicofion and slole that Ihe � Issuonca Fee la .S o LDMP.PIC M
above informatfon is corracf.I ag�ea ta comply with all County �mesr�gaaon Fee I w�
S ordinancee and S�are lawt reloling io building coailrottion, Tmoi Fea Y� .L� IDMA Perm.�1
ond hereby au�horize representa�ives of this Counry to enter'
� upo�the obove-men�ianed property for inspettian purposes.
M1 ���G���yN Z �� SFF RFVFRSE FOR E%�IANATO�Y IAHGUAGE
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