HomeMy WebLinkAbout1254A (3) WORKERS'COMPENSATION DECIARqTION ��
I hereby affi�m ihat I have a cerlificoie of�o�s��,�0 5e�� qpp�ICATION FOR BUILDING PERMIT
� insure,or a certificaie of Workeri Campenstion Insurance,or .
a ce�tified copy thereof(Sec.3800,lab.C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY� �
I PolityNo.�n0�0 o¢CompanyC_S�A�C v[4'�
� Cerrfied mpy is hereby tumi:hed. FOR APPLICANT TO FILL IN ADORE55 -.�.^ '� ��1-�
� Cer�ified copy is filed with the munty boilding inspeo gUILDING ' Y;��� ��� .
tion deporlment, ADDRESS LOCALITY V
Dare Applicont � CiTv 1; ZIP CROSSSST. ��V .11=�'�� �
CERTIFICATE OF E%EMPTION FROM WORKERS' NO.OF e��GS. ASSESSOR
COMPENSATION INSURANCE SIZE Of lOT NOW ON l0T MAP BOOK ' PAGE PARCEL
(This seuion need not be compieted if ihe permil is for one uSE ZONE �P � .
TRACT BLOCK LOT NO. NO. L�S�
hundred doliars(5100)or less.) }�
`, TEI. /.��� SVECU+L
1 certiFy ihor in ihe performance of the work for which ihis OWNER c\t � NO. �•� CONDI110N5 ' Q
DISTRICT GROl1P TYPE FIRE PROCESSED BY V
permi�is issued,I sholl not empioy any person in ony monner ADDRESS ' CONST. ZONE �
so as to 6ecome subjec�ro the Workers'Compensaiian Laws. !p ,n �uL`�' O
v
DOtC Applicant C'lY ZIP STA715TICAlCIASSIFICAIIpN APT. CONDO. .V
NOTICE TO APMICANT: If, aher making Ihis Cerlificate o1 ARCHIiECT OR � � TEL. � �lr iy
Ezemption, you should became subject lo the �Vorker5' FNGINEER NO. CLA55 NO. ��"` DWELI.UNITS_ y
Compensation provisions of the Labor Code,yoo must forrh- � qDDRESS SEwER^nnv ?
winc �omply wilh such pravisions or this permit�shall be . � TF�
deemed revoked. � � CONTRACTOR � Q\�LZ. � NO. � � BK� �. VAIIDATION
LICENSED CONTRACiORS DECLARATION , i��.
I hereby aHirm Ihal I am licensed onder pro�islons of Choprer 9 a�ozE55 G���� NO.3 7� � VALUATION
(commencing wi+h Sec�ion 7000)of Divis�on 3 of the Busineszand \ ��� //_ J,
Professfons Code,and my license is in(ull forte and eHeU. CiTY G Q �C'' Cta55 �'1 5 �''�/ �
/_ (��� 50.FT. NO.OF Np.Of CHECK
LicenSeNum60r�����`�'� Lic.�lo5S�1_� SIZE STORIES FAMILIES ONE
NEW � b
Conira[lo�������H��_Dale ����-^S+Z DESCRIPTION OF WORK .
� I am ezempl from 1he licensing requiremeMs as I am a — � �2 . ADD � � � .
licensed archi�ect or a registered professional engineer _ . ALiER ❑ DATEL rC /� �.� �
, ocling in my profezslonal capatity (Section 7051, REPAIR �
Business and Professions Code). IISE OF 'I
. E%ISTING BLDG: �� f S I�A�' DE.MOL ❑ F�NA�
By _•�t�
LiC.o�Reg.N0. DaIE , APP�ICANT TEL. �
OWNER�BUILDER DECLARAT�ON (PRINTI � NO. - J
I hereby a4firm thai I am e.emp�Irom the Comroctor's titense . -
law for the fallowing reason�Section 7031.5, Business ond ADDae55 -
Professions Code): -E;En�
a6UIlDING
I,as owner af 1he property, or my employees wilh ADORE55
wages os iheir sole mmpensa�ion,will do the work and ' �� z�(1 A
�he strocture is not iniended or offered for sale(Sec�ion �«AIITV
704E,8usiness and Praiessions CadeJ. MOVING TFI. #� � � � �,
� 1,as owner af the properry,am eaclusively contraciing CONTRACTOR - NO. ,
with licensed confractors�o construct Ihe project�Sec- ADDRE55 �,• •4 3 5 0
lion 7044,Business and Pralessians Code). � _
REQUIRFD TOTAL SE78AIX FROM EXIST. , _
CONSTRUCTION LENDING AGENCY SEi 8.4IX YARD HWY pROP.LINE wi�iH ' � - '' ' '4�5 O c��
I hereby aifirm Ihot ihere is a mnstroclion lending ogency fo� FHpNI
ihe performance oI�he work for which�his permit is issued P t. ���� 2"$2
�Sec.3097,Civ.C.�. Si�E
P.L.
Lender'z Nome / " ' �
� lender's Address P.0 Fee S Permi�Fee `. �'� �
W I certify thot 1 have read this opplicotion and slate thol the Issuon<e Fee •�� �
obove information is mnecl.1 ogree to cOmply with all County In.esegoi�on Fee /
$ ordinances and S�ate lows ieloting to building tomtiuttion, To�oi Fea `r�•-�O ,
and hereby authorize represen lives ot this Couniy to enter
� upo/n fr`'e', ve-me��i ned pr erty(o�inspedion purposes.
¢` •r �/ �/ /f�—�� SEE REVFRSE fOR EXPIANATORY LANGUAGE -
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