HomeMy WebLinkAbout1822A WORKERS'COMPENSATION DECLARATION �
I hereby offirm �hot I hove o�e�„���o�e o�mnsen�to self APPLICATION FOR BUILDING PERMIT �
insore,or a tertificote of Worken'Compensolion Insurance,
or o cerfified copy�hereoF�Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY
PalicyNo. Compony BUiIDiNG
� Certified copy is hereby furrrished. FOR APPLICAN7 TO FILL IN_ aooeE55 �d � F � �
I f:l�ferlified copy is fiied wilh the counly bviid�ng inspee- � gUnDiNG �
�« �ion depa��me�L �7 ADDRE55 ',10 � .F L/NE Gd L uT /78
� c �M/n( `�'(/�SO/d/�Y .,' _,�. �. � . .r .._ �
� Dole ���`J9 Applicom Ciiv /f� �` 1iv . •.` IOCAutY .n p�?Q
CERTIFICATE OF EXEM.PTION FRO� ORKERS' ' �• . �'�", � "NO�_OF BLDGS.:-�. �� •�I. � NEARES� 1 /
COMPENSATION INSURANCE . SiZE OF lOi� NOw ON�OT CROSS ST. /l "/�+JQ P< o/)� '
(ihis secGon need not be camplc�ed i}the permi�is ior one • • " , � - ::� ASSESSOR
hundred dollars(5100)or less. TRA�� ��� � a�«K � LOT NO. 0 MAV BOOK PAGE PARCEL
� iEt. . USE ZONE M4P
I cerlify ihm in ihe pertormonce af Ihe work fo�which ihis
. �OWNER�, . NO.-.••, „ NO. ' �� 4-
permif is issued,I thall no1 employ any person in ony manner SPECIAI �i �,� •�. U
so os to bemme subjetl�o ihe Wor4eri Compeneot�on Lows. � /DORESS /� • Z �• CONDrti0N5 V
aTv , O�L� zir �
Date Applicaat qRCHITECT OR T�Z �
NOTICE TO AP7LICANT: I(, ofter moking Ihis Certificala of ENGINEFR N� ,j4/�j DISIRICT GROUP ttFE FIRE PROCESSE�BY
Eaemption, yoo ehould become sobject �o the Workers' � � � ro�/ ' ZOhIE w
Compensarion provisions of the Labor Code,yo�must ta�lh- qDDRESS a
with comply with such p�ovisions o� this pe�mit sholl 6e TEI. STATISTICAL ClASS fC TION APT. CCN90. Z
deemed revoked. CONTRACTOR /�r. Nps�O'���� —
LICENSED CONTRACTORS DECIARATION ���, QA55 NO. DWEIL UNITS
I here6y olfirm thoi I om licensed under provisions o(Chopier 9 ADDRESS �l sr iCE NO. ? � 5�y,�R l�e.v
(mmmencing with Sec�ion 7000)of Division 3 oi Ihe Bu:iness ond ,1 UC.
Profess7ons Code,and my license is in iull force ond effect. � C�TY /��//� ��'� CL455�'�� BK. �. VALIDATION
t�//�-p� � -�� p' 50.FT. NO.OP NO.Of CMECK
license Nvmber �•7(v�P�O l{c,Closs�L_ ` SIZE S70RiES fAMI{IES �Nf
� �" VAWATION :;� ' %I',
sLi�/T�7�i�'2�' �—/G`F� `r� DESCRIPTION OF WO4K c.O � E� Kl— N� = r 5 �D ,' e
Contmcior Dme � ' ADD � / � o o ., . 1
�I am exemp�under�ec. . � ,l L aliER � � � , :.«'7 7
B.BP.C.for this re.oson `y v�x 'n RfPAiR ❑ f e ;.
DOtC: -�y USE Of DEMOI ❑ e � a.-'r`�::_'..
V E%ISTiNG BIDG. � ifr....e
Signo�ure 1` Av�FR,i�S4m��T m�f�N�Y TEI. FINAL � '�� :l'�.R
OWNER-BUILDERDECLARATION NO.SYD�eS( OAiE `O- —
I hereby aHirrrt ihm I om e.empt Lom�he Comractor's License � pDDRESS n _ � Y.2 FINAL
Low for the following reoson($eciion 7031.5,Businets and
Professiona Code): �� l�u* — sY �
❑ EU4DiNG
I, as owner of ihe property, or my employees with � ADDRE55
waqes as�heir sole compenaotian,will do�he work and ���t� ,
tha shucture is not iMended or olfered for sole�Sec�ion
7044,Business and Professions Code). MOVING . TEt.
� I,os owner of the property,am ezclusively contracting CONTaaCTOR � ��
wiih liceneed controdors ro conslrud rhe project(Sec- . qD0aE55
tion 70Ea,Business and Pro(essions Code). �
CONSTRUCTION IENDING AGENCY SET�BACK YARb HWY T�TApRpP.LCNE � WIDTN
I hereby oHirm thaf�here is o to�srruciion lending ogency fo� fROr+i - . .
Ihe performanta of Ihe work for whith lhis permif is isfved P.L. . " �
�"(Sec.3097.Civ.C.). S��E
F.l.
Lendei s Name
� � LDMA Ref.N
m P.C.Fee S Fermit Fee , ,
lender's Address /
� I cer�iiy ihat I have read�his applim�ion and s�ote rhol the �seuonce►ee /�'J iDht4 P/C M
_ a6eve infarmation is corred.I agree to comply with all Covnty Imev�yroiron fee
ordinances ond Slafa laws reloling 10 b�ilding tonslructio�, Torol Fea �� LDMA Pe�m.M
ond hereby outhorize representativee of�his Coumy ro en�er
upon rha ebave-mentioned properly for in5pecfion purposes.
� SFE�EVERSE fOR EX►tANAtONY LANGUAGE
~ S�g�o�vro of Applicont or Age�� Da�e
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