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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. 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