HomeMy WebLinkAbout0866A 0867A (4) WORKERS'COMPENSATION DECLARATION - ^
� 1 here6y aifirm Ihol I have o cerlificole of�o�,e�,,o self qpp��CAT10N FOR BUI LDING PERMIT � '
insure,or p ce�tificate oi Workers'Compenso2�on Insurnnce, - u
o�a cerrified copy rhereoi(Sec.380D,tab.C.) ' GOUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. Company
Ce�ii(ied co is hereb furnished. BUR�iNG ���,a
❑ py Y FOR APPLICANT TO FILL IN ADDRESS L
� Certiiied copy is filed with the county building inspec- BuiloiNG ��
tion depanment. ADORESS � � � ��
Dote qPPlicanl CITV �1L� IV LOCAL�TY
CERTIFI COMPENSATION�NSURAN EORKERS' SiZE OF lOT 1 SO K�f �/?jjj'��w pN�ipTs� O C OSSSST.
(This seclion need nof be tompleled i(the permil is for one ASSESSOR
hundred dpllars($100)or less.� TRAR (� BLOCK LOT NO.� MAP BOOK PAGE VARCEL
OWNER
1EL' USE ONE �P
I certify fhal in Ihe performance o�iha work for which his � ��'f NO.i , .- � , �, QS� j '
permi�is issued,I sholl not employ any person in ony ma er 1� SVEGni
so as to betome sub"ect to the Worke�i m nsation l s. • ADDRE55 0. � J f !� O
i a D_ � � 2oirrt� conroinoNs
,/ utr i 9I'7G> c�
Da�e�.L�APPticont �
pTIC{TO PPIICANT: If, ofter moking�lhis Certifitole o ARCHITECT OR El.� p(f DiSTRICT GROUP 7YPE FIRE PROCESSED BY Q
FNGINEER � J1J� NO. �
emption, yo� should become sub�ecl to fha Wo�kers' CO T. ZONE F—
Compensmian provisions of ihe Labor Code,you must forfh- _��, � � 1� ����✓ C w
with comply ith s�ch provisions o� �his permi�shail be AO�RFSS
deemed revORed. ,� tE�• STATISTICA�QASS�FICATION APT. CON�O. U
CONTRAROR Np. z
LICENSED CONTRACTORS DECIARATION ���. QASS NO. �'O DWELL.UNITS
I hereby aHirm that I am licenxd under provisions of Chop�er 9 AD�RE55 NO.
(tommencing with Sectian 7000)of Division 3 of tha Business and ��� SEWER MAP �
Proiessions Code,ond my license is in fuli forte and eNect. CIiY M55 VAIIDATION
� 50.FT NO.OF NO.OF I CHEIX BK' �''
, Litense Number LIa Closs SIZE STORIFS FAMILIES ONE
� ' � VALUATION �
DES�RIPTIONOF WORK � N� = c �
Contrac�or Dale V ,
A�D
❑I am exempl under Sec. �� L O .
B.BP.C.for�h�s reoson G�w u�,� atieR
� -t O f'� G2l�17�••�Y'e=i2�•�i� REPAIR � _
Dote: EXIST�ING BIDG. S-h�',D DEMOI ❑ �O S b.b F�
Slgnafure AP�vR MT ��!,/ q El N FINAL �• • • •'�J
OWNER-6UILDER DECLARATION �p� t� rr DATE
I hereby affirm thot I om exempt from the Conhacror's Lfcense qDORESS (f V7�j �(`��(Cy• '�� �' � • •��G J
Low for the follow�ng reeson�Secr�on 7031.5,Busfness and FINAL
Pr fessions Coda): pqc N 6y � �
BUILDING ;'�;
I, as owner of 1he properfy, ar my employees with ADDRE55 • � `� ^
' wages os Iheir sole campensation,will do rhe work ond � , ��� G—a 8
the s�ructure is not intended ar offered far sale(Section ����Tr
7044,Buslnees ond Professions Code�. MOViNG TEt.
� I,as owner of the properly,am e.clusively contracting CONTRACTOR NO. �
wiih licensed confroctors ro consr�ucl ihe project(Sec- pDORE55 '
tion 70<d,Business and Professions Coda�.
CONSTRUCTION LENDING AGENCY SET�BACK YAR� HVJY r�Tp'p OTP,UNEF WiDTH �O&6 7 A
I hereby affirm thaf ihera is a conshuc�ion lending agency for FRONi �� � � , � �
ihe performance af ihe work for whith this pe�mi�is issued P.t.-
(Sac.3097,Civ.C.). SiOE I • •S�,J O
P.L. �
lender's Name
�j �[ LOMA Ref.N • • •,rj J;;(J u
� Lender's Address P.C.Fee S �d� Permii Fee j S� '
a&� 2-8�
��,, I certify thol 1 have read this application and slata that tha Iss�ance Fee 1 0'�� LDMA P/C N
° obova Informa�ion is correN ogree io comply with all Covnry inves�igm��on Fee f�>
p' ordinonces and State low r lofinq fo b�ilding conelruclion, iorol Fee ��1 ✓ LDMA Perm.N
ond her y aulhortza repr s nlotivas o(Ihis Counly to enfer
� upon th bov menllone roperty for inspettion pvrposyes.�
m ` � SEE REVERSf fOR F%PUNATORY IANCVAGE
Signowre of Applimn�or ent pote'
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