HomeMy WebLinkAbout1822A (10) WORKERS'COMPENSATION DECLARATION �
I hereby offirm �hot I hove o certificale o�mnsen�to self APPLICATION FOR BUILDING PERMIT �
insore,or a tertificote of Worke�s'Compensolion Insurance,
or a ceriified copy ihereoF�Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY
PalicyNo, Company Bl11lDING
� Certifled copy is hereby furrrished. FOR APPLICANT TO FILL IN_ aoo&E55 �d /I? F � �
I f:l�fertilied copy is filed with ihe county bvilding inspeC � gUIIDING �
�« �ion depa��men�. � ADDRE55 ',10 � .� L/NE Gd L uT /78
I G �anv►+� �2�PSo.��Y . , ,. , . �,- ..`
� Dole ���`J 9 Applirom CiTV /fL I � 1i7 IOCAutY ,n O�?Q
CERTIFICATE OF EXEMPTION FRO ORKERS' ' �• . �'�", � "NO�_OF BLDGS.:��.-� •�[. � NEARESi 1 /
COMPENSATION INSURANCE ' SiZE OF lOi� NOw ON�OT CROSS 5T. /l '/�+JQ P< o/)� '
(ihis secGon need no�be cample�ed i}the permi�is ior one • • " n �j , � - ::� ASSESSOR
hundred dollars(5100)or less. 1RAC1 .�.0 O BLOCK ' �OT NO. O� MAP BOOK PAGE PARCEI
� iEL . USE ZONE M4P
I cerlity ihm in ihe performonce af Ihe work fo�which ihis
• OWNER�: r NO'-.-": .� NO. ' ��� 4-
permif is issued,I thall no1 employ any person in ony manner SPECIAI �i �,� •�. U
so os to become subjet��o�he Wo�4eri Compeneotcon Lows. � /DORESS /� • Z `• CONDRi0N5 V
aTv , p�L� zir �
Date Applicaol qRCHITECT OR T�Z �
NOTICE TO APVLICANi: If, ofter moking Ihis Certificala of ENGINEFR NQ ,j��j DISfRICT GROUP ttFE FIRE PROCESSED BY
Eeemption, yoo ehould become sobject �o the Workers' � �-� ro�I ' ZONE w
Compensarion provisions of the Labor Code,yo�must ta�lh- qDDRESS a
with comply with such provisions o� this pe�mit sholl 6e TEI. // STATISTICAI CLA55 IC TION APT. CONDO. Z
deemed revoked. CONTanCTOa /qr. NOST���f�
LICENSED CONTRACTORS DECIARATION ���, QA55 NO. DWEIL UNITS
I here6y olfirm thoi I om licensed under provisions of Chopier 9 ADDRESS �l sr iCE NO� � � 5�y,�R M4v
(mmmencing with Seciion 7000)of Division 3 oi Ihe Bu:iness ond ,1 UC.
Prokssions Code,ond my license is in(ull force ond effect. � CiTY /��//� ��'� C1A55�''7� BK. eG. VALIDATION
� �C. �� 50.FT. NO.Oi NO.OF CMECK
liC@n50 Numf�er ����� lk.C�ass�� �"� SIZE STORIES fAMiUES ONE
,�v��r G- �" VALUATION :;� � ;%I',
SLiM/h/T/"/�•7"'^ 4/—/G�FJ � DESCRIPTION OF WO4K c.p � E� �fi— A D O = /� 5 �D �' e
Contracbr pote - � � o � *, • �
�I am exemp�under�ec. . � ,l L aliER ❑ , � , .,�`?7
B.BP.C.for this reoson `y v�x 'n RfPAiR ❑ f e �.
DOtC: -�y USE OF DEMOI ❑ e � a.��r,�::.:..
V E%ISTiNG 9lDG. � i1r....e
Signoture 1` Av�PRI T)S4M/TG/T /11�7'f�N�Y TEI. FINAL � '�1 :l'^.��
OWNER-BUILDERDECLARATION NO.SYD�eS( OATE `O- —
1 hereby aHirrrt ihat I om e.empt Irom�he Comractor's License � aDDRESS n _ � Ys FINAL
Low for the following reoson(Seciion 7031.5,Businets and
Professione Code): �� f�Cu�r — sY
� BUiIDiNG
I, as owner of ihe property, or my employees with � ADDRE55
wages as�heir sole compenaotian,will do�he work and ����t� ,
the shucture is not iMended or olferrd for sole�Sec�ion
7044,Business and Professions Code). MOviNG . TEt.
� I,os owner of the property,am ezclusively contratting CONTRnCTOR � ��
wiih lice�eed controdors ro conslrucl the projecf(Sec- . qDDRE55
tion 70Ee,Business and Professions Code). �
CONSTRUCTION IENDING AGENCY SETOBACK YARb HWY T�TApRpP.LCNE � WIDTN
I hereby ofiirm tha�ihere is o to�srruciion lending ogency for fROr+i - . .
Ihe performanta of Ihe work for whith lhis permif is isfved P.L. . " �
� (Sec.3097.Civ.C.). S��E
C.l.
lender's Name
� � LDMA Ref.N
m P.C.Fee S Fermit Fee , '
lender's Address /
� I cerliiy ihat I have read�his applico�ion and s�ote rhol the �seuonce Fee /�'J iDhl4 P/C N
_ o6ove infarmafion is correcl.I ogree to mmply with all CovnN Inveu�go�ron Fee
ordinancei ond Slafa laws reloting 10 b�ilding conslructio�, Torol Fea �� LDMA Pe�m.M
ond hereby outhorize representativee of ihis Coumy ro enier '
upon iha ebave-menlioned properly for inspecfion purposes.
� SFE lEYERSE FOR E%►LANAtONY U1NGU�GE
~ S�gnorvre of Applicont or Agent Do�e
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