HomeMy WebLinkAbout1121A (5) 1 WORKERS'�COMPENSATION DECIARAT�ON �
; �
, I hereby offirm ihat I hove a ceriificoie of tonsent�o self APPLICATIQN FOR BUILDING PERMIT
insure,orc.ceriilicaie oi Workers'Compensoiion Insuronce,
or a certified copy ihereoi(Sec.3800,Lab.C.) � � � �
Polic NoDLYY�C��o m an COUNTY OF LOS ANGELES BUILDING AND SAFETY
v a vTi�2f}.0 S1nT,q L
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
aooaes��-� � C
� Cerlif�ed copy is iiled wilh Ihe covnty boild�ng inspec- BURDING
�ion deparrment. qooRES - TR N T
I Do�e O I Applicant � CITY L/v T Z�P LpCHLITV /U
CERTIFICATE OF EXEMPTION FROM W RK S' NO.OF BLDGS. / NfAREST / �/
COMPENSATION INSURANCE SIZE OF tOT NOw ON LOT CRO55 ST. �
(This section need not be completed if the parmif is for one � t .455ESSOR
hundred dollars(EI00)or less.) TRACt etOCK tOt NO. i Mqp gpp( PAGE P RCEt
' � TEL U ZONE MAP
OWNER �-��
I cerlify Ihot in the performante of the work for which fhis � ^ IY1 1 NO 7 � - �
permit is issued,I shall nol employ any person in any manner qDDRESSYW "N'(� b QL" �EGnL � r ' r� ��
so as to become subject to Ihe Workers'Compensolion Laws. CONDITIONS vJ 0
CITv. 21P / � V
Dale Applicant ARCHITECTOR TEI. ��
NOT�CE TO APPIICP�Ni: If, affEr meking this Cerlificafe ot DISTRICT GROUP 7YPE FIRE PROCESSED BY O
ENGMEER NO.
Exemption, you should become svbject lo Iha Workers' ^'') p C'OtJSi. ZOtJF ):
Compensa�ion provisions of tha Lebor Code,you musl(orih- qDDRESS f� �\3 � �,�} ly
� with comply wilh s�ch provisions oi ihis permif sholl be • TEL: _��iJ STATISTICAL CIASSIFICATION APT. CONDO. N,
deemedrevoked. CONTRACTO� N Y
UCENSED CONTRACTORS DECLARATION „�, ��� apSS NO. Z DWeiL UNiTS =
I hereby nffiim�ho1 I om litensed�nder provisions of Chapter 9 a�DRE �� NO. ,Q
(commencing wirh Section 7000)of Division 3 af�he Business and ��� // /� SEVJER MAP
Professions Code,and my license is in full force ond eHed. CiTY AL .(r �U�.55 c:.-GO� VAI�DATION
C� L, SO.FT NO.OF NO.OF CHECK BK' �''
License Number���d� T Lic.Clais� SIZE STORIE$ FAMIUES ONE
YALUATION
eonvac�o -- Dare �0-I•3�,�'1 �ESCRIPTIONOFWORK N� � _ ?7� �
�I em e.empt der Se �'�� T�� ADD � SJ , �� � 2 1 A
n,,� AITEB �
B.BP.C.(or lhis reosan C�.C.�V � REGAiR � S . #• • • • • �
Date: USE OF DEMIX ❑ I • •4 9 2 5
EXISTING BLDG. S Cr�7
Slgnotuie APPIICANT n TEI. FINAL
OWNER-BUR�ER DECLARATION PRiNT t� N�9 - DATE • • •4 9 2 5 c=.,
. I hereby a((�rm�hot�om e.empr from ihe Controclor's License n ' 1 l/ �
law ior�he following reason(Saction 7031.5,Business and /+DDRES�'%CY� V R(.�-� FINA I 0,1 3-8 7
Professions Codej: ,h By
O6UIl�ING
I,as owner af tha properly, or my employees wiih nooa[SS
woges as their sole compensmion,will do�he work and �p�q��TY ,
�he shucture is na�in�ended or offered for sale(Settion
70aa,B�siness and Professions Code). MOVING TEt.
� I,os owner oi tha property,am exclusively conlracling CONTRACTOR NO.
with licensed contrattors to constrvct tha projeU($eo- qDOBE55
�ian 704G,Business and Proiessions Code).
REUUiRk� TOTAL SETBACK
<ONSTRUCTION LENDING AGENCY SEt BaCK YAeD Hwr vROv.iwE wiDTri
I here6y aifirm that ihere is a construction lendinq agency for FRONt
�ha performance o!the work(o�whith Ihis pe�mit i5 i55�ed P.L.
(Sec.3097,Civ.C.). SIDE
P.l.
lender's Name
3 �e lDM4 Rei.M
m lende�'s Address P.C.Fee S Permit fee �
� I certify thot I hava read Ihis application and s�ale that Ihe Issuance Fee � O' � v LDMA 7/C M ,
_ obova info�maiion ie corroct.1 aqrea ro tomply with all County In.esugouo�Fea
ordinances and S1ote laws relating lo buildinq tonstruclion, To�al Fee LDMq perm.M
ond hereby oa�horize representatives af this Coanry to enter �
� upon the obove-mention properry for inepection purpases.
( m /v��3 SEE NEVERSE FOR E%PIANATORY LANGUAGE
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