HomeMy WebLinkAbout1845A . WORKERS'COMPENSATIOIJ DECLARATION ��
� he�ebY�ff�r�, ,ha, � h��e a certifimte of�onsa�,�o=e�f A�PLICATI�N FOR BUILDING PERMIT
- Insure,or a certificafe of Workers'Compenstion Insurance,ar
- a�ertifed copy thereof„(Sec.3800,Lab,..�':j COUNTY OP LOS ANGELES BUILDING AND$APETY
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PolicyNo. �':��l3�x'.vt. P Y °�'.�.,?.,, � ...+'.
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Certified copy is hereby fumished. Rui�oiNG ",,, p � '�_
❑ . FOR APPLICANT TO FILL IN ao�aess i �'`• '' .'�C:
� Certified mpy is filed with ihe count�,r'6yilding i. c BUIIOWG j� " . "p
, tionclepar}ment. �,li ' �� ADURESS ,�.'�J jf- .rfr..%r'.n�,.�'� LOCAIITY .Y�� � .•
. �ate �..!..�`f�� APplicant . ���i.f r�f�". � CITv���I'l�;'.:� ' ! 1��..V ZIP CROSSSST ,�'.,s _ �..,.Y
A
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF aiocs. A55Es5oR �
� COMPENSATION INSURANCE 9ze OF�OT NOW ON i0i MAP BOOK PAGE PARGEL (�
{This settion need not be completed if�he parmit is for one - US zONE nnAP � U
TRACT 610CK IOT NO. � Fr NO
hundred dollars($100)or less.) .�{. �
' ,/ I TEL. '�+ ^;�,^�i, SPECIAI
l" 'f�;..E�.;t:'i.. ''�;t,.t...� CONDITIONS � 7i
� � I certify that in ihe performance of ihe work for whlch Ihis OwNFR , NO,'��l�`��~.`?,'f� ..
DISTRICT GROUP TYPE FIRE PROCESSED BV
: permit is issued,I sholl not employ any person in any manner ,.�„�� ^ >'
so as to bemme subject to ihe Workers'Compensation Laws. ADDRE55 'r e .✓t'��i: ; CONST,.. ZONE, ,, '-„ ,� �
�{�� i'i•..,; /`�• �I�.� ': ,!'.�:.'� 't�,� �
Date Applicant CITY � __ ��P �STAl15TIC:AI CL�SSIHCATION APT. CON00. �
�NOTICE TO APPLICANT: If, ofter making this Gertificate oF ARCHITECi OR TEL .j ��
Exemption, you should become subject to the Workers' FNcweek NO. CLNSS NO. Y�, uWeu.Uwis` �
. Compensqlion provisions ot Ihe Labor C.ode,you musi forrn- qUDRf.SS ��JJE2 f.'�A? 1—
with comply with such provisions or ihis permii shall be '
'deemed revoked. TE�� gK p�; VALIUATION �
' CONTKACTOR NO.
LICENSED CONTRACTORS DECLARATION !IC.
' I hereby aYfirm that I am licensed under provisions of Chapter 9 ADDRE55 NO. VALUATION
. (commencing with Sedion 7000)of�ivision 3 of ihe B�siness and 11C � .
_ Protessions Code,and my license is in full force ond eltect. CITY QASS b , ,'""1
' �/ SCa.FI.�, f NO.OF NO.UF CHKK � '
:-License Number '~���'��«•�� Lic.Class'.fµ•���'S�"+-�� SIZE�--+�A SiOR1E5 FAMILIE.S ONE �
.. �.'Coniractar ik'r�`�. . � �y� e�'r, �. DESCRIPTIONOF WORK � �- .�;7t:'�f-'.�.�� NEW � � . ,.. ,
fPi-�w Date� ,s �`�d...'—
�,❑, I om exem t from the licensin ,,,..$)i'> .i�¢" ADo �
p g requiremenis as I oin a J
� � licensed architect ar a regisfered professional engineer �i AITER � F(NAL
. . acting in y professional capaciry (Section 7051, r�` � ❑� L�ATE � '
REVAlR
' . Rusiness ond Professions Code). USE OF FINAL
" � ` E%ISTINGBLDG. DEMOL �,, B :
� Lic.or,:Reg.No. Dqle APPLICANI 7EL Y
� � � OWNER-BUILOER DECLARATION (NRIN�� NO.
. � I'hereby affirm that I am exempi fram the Contracfor"s License -
Law for the fo4lowing reason(Seaion 703L5, B�siness nnd � ���RFSS
� Professions Code): PRESENT -
BUILOING
'� �, ns o e nf the prooerty, ar my employee5 wiih AU�RESS �
wages as iheir sole compensation,will do the work and .
ihe struUure is no7 intendnd or oftered for sale(Section LOCALiIY
7044,Business and Professions Code). MOVING TEI -
� I,as owner of the properfy,pm exdosively mnirocting CONTRACiOR ___ NO '� ,
- wi�h licensed wnlraUors to conshuct Ifie project(Seo- qpoRESS
� tion 7044,8usmess and Professions Code�. -�
' REG7UINED TOIAL SIiBACK FROM f.%IST. �
CONSTRUCTION LENDING AGENCY SfT nnCK Yneo Hwv pROa iiNE WID7t-I
I hereby aHirm thof there Is a conslrucllon lending ogency lor I uONT �
the pertorniance of ihe work{or which ihis permll is issued i>L �
: (Sec 3097,Civ.C.). SiUt '.' � �
a l iF,i `%F�r:.}f�
. Lender's Name
. J'-..'T�'b'a !'�.�,:��
P.t:.Fre S Perm t Fr� ' f,
:Lender's Address__ fi,�;� } ���f �.
I cerl�fy ihat I hyve reod th s applicat-on and s�ate thot th issun v.e FeP - ,
above nformatibn is correct I qqree to comply wrth c II Counry i��rs� �ion Fee �?',s^�k x� � ���
ord nances qp�i Stnte laws r•el�J i ng to buJdmg constrod o�, �� . , i Y ex.�t�i.§
't.• , Tntnl Fn�� .,�"t .
' and here utF�r¢e,repr e¢lalives of ihis Couniy ta entE � � � . ��e'` � ��� t
� . upo i�{i'��g e �'i d perry for�nspecFon purposes ° `��'�
� � ✓` "�/ �,.1'�ffjt j���'� r't,J"f SEE REVERSE FOR EXPLANATORY LANGUAGE
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� $'iynotufc oF ApPlicani o� gont Untc , ' ��
�.