HomeMy WebLinkAbout1632A WORKERS'COMPENSATION DECLARATION � .
�hereby affirm 1ha1 I hava o terfificote oF consem to selF qpp��CATION FOR BUILDING PERMIT
insure,ona ceNifica�e o(Workers'Compensalion Ins�rance, •
or o certified copy ihereof(Sec.3800,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company �
Certified co is hereb furnished. BUi�DING ^+ Cl ' I
❑ PY Y . FOR APPLICANT TO FI IN nooaess � J� � � �'`
� Certified mpy is filed with the count building inspeo- BunDiNG C�aEj ' ) '
tion deparlmenL ADDRE55 O% . �.• LOUtRY �
r _._."' " _ _ " "_"_' C NEAREST t S�.
Date �� U �"APPlicant , CITV I/h'�1M ZiP CROSSST. � ti�� �'�S_A� �
, .CERTIFICATE OF EXEMPTIOIJ ROM WOi�KERS' NO.OF BLDGS. ASSESSOR '
� COMPENSATION INSURANCE - SIZE OF LOT NOW ON LOT MAP BOOK 7AGE PARCEL �
(This section need not be comple�ed if tha permit is�for one � � ' ' � US Z NE MnP -a j
hundred dollars(E100)or less.) � . , iRAR Z LOCK OT NO. � ��� NO. � � �d S� �� 3 � I
/ TEL SPECIAL I
I cer�ify ihot in tha performance af the work for which�his �NER� /1 r+��• �. �-� � �� CONDiTIONS a �
permil is issued,I shall not employ any pe ony manner y�,� r- � Di5ie7Ci GkouP TvvE FiRE PROCESSED Br O
so as to hecome subject to the Wo�ke pens �on pL �^�S. ADDRESS (-U l� �ty� cONS�,,.{i ZO E. ^ U 1
az a��a - �� -... ��T� ` i' ��P �ihG ' d �v� � \ `c . a
Date Applimnt - STATISTICAlCLA551FICAlION APT. CONDO. t-
NOTICE TO APPUCANT: If, after aking Ihis e�liiim��j6( ARCHITER OR 7E1. _�� V
FNGiNEER NO. CIASS NO.�DWEIL UNITS ul
Exempiion, yo� should become subject eo tha Wor1c(rs' �
Compensation provisions of the La6or Code,you must foRh qD�RE55 SEWER nwP '�
wilh tomply with such provisions or this permit shall be p TE� �
deemedrevoked. ConrrRnCtO �U�F�`� -
NO. BK. PG, � VAIIDATION
IICENSED CONTRACTORS DECIARAT10N UC. '
I heraby affirm ihat I am licensed under provisions of Chapler 9 ADO. SS NO. VALUATION
(tommencing with Setfion 7000)of Divisio�3 of the 8usiness and ��� ^ '
Professions Code,and my license is in full force and effect �iTy Q ��- nqu y`3 �`j` �
Sq.FT.� OF NO.OF / CHECK ,
Li[ense Number lia Clase SIZE i' ORIES FAMILIES ONE
NEW � S
Contrvclor pa�e �ESCRIPTION O WORK ,
�I am exempf under Sec. �" g' ADER ❑ FINAL
B.SP.C.for this reason � OATE �, �
REPAIR �
Date: EX S7�ING BLOG. 9i ` MOl � BINAL �
Signat�re APP�ICANT TE�. / y
OWNER-BUILDER DECLARATION PRI -Z�
I he�eby offirm that I am exempt from Ihe Contrattor's ticense �3 ' Ch , r
law for tha follow�ng reason(Secrion 7031.5,B�siness ond ADORESS
Pr (e7sions Coda): PRE..ENT
BUILDiNG
I, as owner of tha properly, or my employees witfl ADDRESS ; � (;�j.L A
wages as their sole tompensation,wiil do the work ond
the shucture fs not intended or of(ered for sale(Saction ����TY . �� � o�� � �
7044,8usiness and Professions Coda). MOviNG TE�. _
� I,az owner of Iha property,om e:clusively contracting • CONrRnCroR NO. I ` •4�O�
w(Ih Ilcensed conlrvclors to consir�ct ihe praject(Sec• ADDRE55
fion 7044,Buslness and Professions Code). � t��Q�j
REOUIRED TOTAL SETeACK fROM EXIST. `�
CONSTRUCf�ON LENDING AGENCY SET BACK �'ARD HVJY pROP.�INE W�DTH , '' � `? , 7_�4
i hereby affirm thot fhere is a mnstruction lending agenty for FRONT � - �
tha performanca of the work tor whith this permit is issued a.t. � �
tSeC.3097.Civ.C.). - SiDE .- . � • .
P.L .
Lendei�Nama � . ' ' .. .
� Lendar's Address P.C.Fee E Permn Fee j _ , � .
� 1[artify lhot I have reod this applicalion ond slole Ihot the lesuon<e Fee �
� obove information is correcl.I agrea to comply with all Co�nry inves��gar�on Fee ;�
ordinonces ond Stote laws elating fo building constr�ctian, To�al Fee � `� '
Cl and hereby auth i� semmi this Co y to emer
� �pon�he o6ov men d prop for in c' n pvrposes. ,
� )? . d2 � SEE REVERif FOR E%PIANATORY LANGUAGE
SigYfature of Appli nl or pc�e ' m�
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