HomeMy WebLinkAbout0940A (5) WORKERS'COMPENSATION DECIARATION � .' �
I hereby affirm thar I ha�e a tertifitole of�o�,e�f,o seif qpp��CATION FOR BUILDING PERMIT
insure,or a certificate of Workers'Compensalion Insuranca,
or o ceriified copy ihe�eof(Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company '
� Certified capy is here6y furntshed. FOR APPLICANT TO FILL IN ADDRF55 ��'�0 'S 7�C�.�iCJ Ld/NA .�'
� Certified topy is(iled with the county building inzpec- BUUDING�7 �7 D„�
lion department. ADDRESS aC,� In lOG4LITY ��rf�4N+� ciy
�l � � NEAREST f�rN����
Date Applicant CITV rl ZIP CROSSST.
CERTIFICATE OF ExEMPTION FROM WORKERS' NO.Of Bio�S. a5SE550R
COMPENSATION INSURANCE , 512E OF lOT NOW ON LOT NU1P BOOK PAGE PARCEI
(This seclion need noi ba compleled if ihe permit is for one �`�f _ /� USE ZONE f.�nP
hundred dollars(E100)or less.) � TR/+� BLOCK �07 NO. 4� �J�/ NO. �� —3.3J
TEL.o SPECIA� �
I certify fhat tn the performante of the work for whicb Ihis �� �"/NER �� � NO.D� '03 S�no �ON�ITION$ p.
� DISIRICT G20UP TYPE FIRE PROCESSED BY
permit is issued,I shail nol employ any person In any monner � � y �
eo os to hecome subjecl ro Ihe Workers'Compensation laws. j AD�RES O / /L,/? � � /� �r CONST. z � � U
! / (�.5 G�Jf1 c:, a
Date � /G-� IicaM . r� ���� ����P '
PP ' ' ! AIRCHITECT OR^7 � TE��� STATISTICAL CUt55 ICATION qpT. � prypp, �
NOTICE TO APPLICAN� If, afler making is Cerlifitale'of ENGMEER�:-�� j I�. �J3��l- No. S5 �c�nss�No. �'� oweu.uNirs_ ,�„
Exemprion, yoo should become �sub�ect to tha Workers' �f �n
Compensofion provisions�of fhe Labor Code,you must forth- ADORESS�� rx 9 � �S OC SEWER AMP �
ith comply wi�h such provisions or this permit shall be � �
deemed revoked. TEL n —
�^NTRAC70R ���n O NO.C ^� BK. �, VALIDAT�ON
LICENSED CONTRACTORS DECLARATION �� �{-� ygsa�
I hereby affirm rhot I am licensed under provisions of Chopter 9 qDDRES�7/y �/�1C.�/� � l'�i1 NO. VAtUATtON
(tommencing wi�h Seclion 70W)o(Division 3 of the Business and n �rr�
Professions Code,and my litense is in full force and effect. CITY Ll�L 14"/`�� �� CU+SS C-"'� S o� V a • . �
�Q�� �� S(].FT�.o�/�1 NO.OF NO.OF CNECK �
litense Num6er o liC.CIa55� ; SIZE._.[/ STORIES FAMItIES ONE
Q /�'� i DESCRIPTION OF WORK N� E
Contrattar Dale , �
❑1 am exempt ander Sec. � L O , _ A�� �
/ ALTER � FINAL�
8.8P.C.for this reoson 7 V �a � t REPniR � DATE � ,
USE OF DEMOL
Data: �_ FINAL
/ EXISTING BLOG. ❑ By C �
SignatureL ��Q rC�"'4�� APMICAN7 TEL. � ����
fOWNER-BUILDE EQARATION PRiNT NO.
I hereby offirm thol I am eKempl from tha Contractor's License
Law for the following�eason(Section 7031.5,Bosiness and A�oriE55 L���GQ
Professions CodeJ: N �
OBUIIDING o O 4�O A
I, as owne�of the praperry, or my employees wilh ADDRE55 �� /� �� a � p
wages as thair sole tompenso�ion,will do the work and -
the structure is nol intended or offered for sale(Settion ��'��T�" . /(� , �+� � , � �1
7044,Business and Pro(eesions Code). MOVING tE�' ,A///L //C y/f/G/' � • �3�7 5
� I,as owner of the ro e y 9 CONiRAC7Oti NO. y ,
p p rty,am exclusivel contracfln � 7 D
with licensed conlratloro fo tonstruct the project(Sec- qooRESS �j�7��
tion 7044,Business and P�ofessions Code). • •
REOUIRE� TO1AL SETBACK FROM E%IST.
CONSTRUCTION IENDING AGENCY SET BACK YARD HWv PROP.tINE WIDTN , O'I,� O`B 4
I here6y affirm�hm fhere is a construction lending ogency for feoNt
tha performance of the work for which this permit is iss�ed P.l.
�Set.3097,Civ.C.J. SIOE
P.l.
lender'e Nama / �
$ ' P.0 Fee E Permil Fee �((�.�
lender's Address
� I certify�hat I have read fhis appllco�ion and stme Iho��he � ise�o ce Fee ��. J�
� above information is mrrecl.I agrea to comply with all Counly Investigm�on Fee � l �
S o�dinantes and Stofa lows relaling to building construc�ion, Totol Fea �[s� • J'—�
tl ond hereby auihoriza representaifves of this Counry fo enter
;� upon tha obove•men�ioned property for inspaction purposes. ' � - �
"JD� � �
{ SEE REVERSE FOR FXPUNAiORY IANGUAGE � , �
I� _ -- Signalure ApplicoM or Agem —'-' -.- po�e . . . '
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