HomeMy WebLinkAbout0978A (5) ,
� WORKERS'COMPENSATION DECLARATION
I hereby offirm tha�I have a cerlifitole of�o�5e�,�o self APPLICATIQN FOR BUILDING PERMIT �
insure,ar a certificole af Workers'Compensolion Insuronce,
or a cer�ified copy thereoi(Sec.3800,Lab.C.) -
COUNTY OF LOS ANGELES BUILDING AND SAFETY '
PolityNo. Company OUILDING �� " � ;i
� Cenified topy�s hereby furnished. FOR APPLICANT TO FILL IN '� '` ' —�-f ' '
ADORE55 � ��
� Cerlified copy is filed with the counry building inspeo- gU�LDING - / . . "
I� lian depo��menl. ADDRE55 .-•�/irJ C �'�''• � �� !� •
` Dote Applicant Ciiv ;� i�� Zia lOCAIiiv
�. CERTIFICATE OF EXEMPTION FROM WORKERS' � �NO.Of BLDGS. NFAREST
COMPENSATION INSURANCE SIZE OF LOT NOW ON lOT CROSS ST.
'` �This seclion need not be completed ii tha permit is far one --�^ ASSESSOR y;
hundred dollors(E100)or Ie55.) TRACT BLOCK LOT NO. --• INAP BOOK PAGE PARCEL O
�. � I "1�i� .' ; /.'. ' TEI. USE ZONE �P
I cenify�hot in the performance of the work lor which this OWNER:=i�. � NO. � �/' � / U
� � permil is issued,I shall nat employ any person in ony manner _,, , SPECIAI W
f , so as lo become s�bje�t Io ihe Workers'Compensolion Laws. ADDRE55 �ONDITIONS "�
W
j/��.%r`� . ,. . . _ ... � � CITY -' � � ZIP �-.
Date�' � Appliconl� ' ' ' ARCHITECT OR TEL a
. NOTICE TO APPLICANT: If, oNer moking lhis Cerlificote of � DISTRiCT GROUP ttPE FiRE PROCESSED BY ¢
ENGINEER NO.
ENemption, you should 6ecome subject �o �he Workers' � CONST. ZONE O
Compensa�ion provisions of the Labor Code,you must forlh• ADDRE55 � � � Q
�ih comply wiih such p�o�is�ons or rhis perma sholl be - TEL. ' -- - SiAT15TICAl QASSIFICATION APi. / coNoo. �c
� deemed ravoked. CONTRACTOR�.-� •=. '� !�i NO. /�'T . ;�.� W
UCENSED CONTRACTORS DECLARATION , ;J, ,�� ._�f i t �f NO _ �,, M55 NO. '�� DWELL.UNITS F'
I 1 hereby affirm that I am licensed under provisions of Chopier 9 ADDRE55.`.:i:. :" _• � ��R�P
`, (commencing with Section 7000)of Division 3 of the Business and � � ���, �
f� Profess�ons Code,and m license is in foll forte ond eNect. CITV:'��''�! ��'�f/=/'' ctnss I�
Y � BK � VALIDATION
� : ' S0.FT.-;:., NO.OF NO.OF CHEIX
I License Number - Lic.Class �� SIZE ':�!" STORIES . FAMI�IES ONE ,
� � VALUATION
` '� � • `'--=:1�?'e�-' DESCRIPTION OF WORK NEW .
Conlractor'• ' • � Dale �- � . . " ' ADD � s f 7�' '� ' .
!
� ❑I am e�empt vnder Sec. �-- " //` �•'� ' l:'i�:�' - � ..
'ri.'� .� . ,• � AUER
B.BP.C.for this reoson ��/ , .t..' ,1- %'�.':�'i REPAIR � s
USE OF
Da1e: E%ISTING BIDG. DEMOL ❑ i�(f:',l;F'%!,
Signoture APPLICANT TEI. FINAL � �:��'��..'�;� �
OWNER-BUILDER DECLARATION (PRINT N�. DATE � ' " �'
I hereby offirm Ihat I am eaempt irom the Contrattor's license -
Law for�he following reoson(Sedion 7031.5,Businss ond A�DRE55 FINAL .��"��°.''• '-C
Professions CodeJ: rv, By � �
� I, as owner oi the property, or my employees wiih ADDRESS � • e�• A` f'F,
wogei as their sole rompensation,will do�he work and �t j,'-��i?,
I �he efructuro is not intended or offered for sale(Settion ��`��Tr ,
7044,Business ond Prolessione CodaJ. MOwNG TEI.
I � I,as owner of the property,am axclusively conlracting CONTRACTOR NO. �
wiih Ilcensed tontraCfOrs t0 consfru[I the project(Sec- ADDRE55
I iion 70a4,Business and Professions Coda).
I. CONSTRUCTION IENDING AGENCY SET�BACK YARD HWY r�TApROP.LCNE WIDTH
( . I hereby aiiirm iha��here is a mnstruction lending agency for FttaNi �
�" Ihe performance of tha work for which this permil is issued F.l. '
�; (Sec.3097,Civ.C.). � SioE
� P.l.
I, lender's Nama
- IDMA Re1.N
I m P.C.Fee S Permit Fee ,''a' ��-
g Lender's Address
I g I carlify that I hava read this applimiion ond s�ate�hot ihe Iseoance Fee `` �� LDAM P/C M '
above informalion is correcl.I agree to tomply with all Co�nty Inveetigotion Fee
� o ordinances and Stote laws relaiing to building com�roalon, • ���.
� „ _ ond hereby-%ulhoriza representatives of this Counfy to eNer To�o1 Fee �`� LDMP,Perm.N
� � opon�he_obova-men�ioned property for Mspeclion purposes�-.,.�
��� ��_;Yl'>r •' ^(, %:l _
1,`�!�'n'�i a� �C--�,� / L ,�, SEE REVERSE FOR EX►LANATONY IANGUAGE '
I�,m . ,._Slqna(vre o}Apy6fdm or AgeM / Doie �
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