HomeMy WebLinkAbout0938A , _. ..... .. .. .. . ..... _. ... . � . . . . _. _
WORKERS'COMPENSATION DECIARATION "' � . � ��
��e�eey afiirm tha�I have a tertiiicafe of�o�=e�„o=e�f APPLICATION FOR BUILDING PERMIT� �
insure,or a certifica�e of Workers'Compensa�ion Insu�ance,
or a cerriied copylhereof(Sec.3800,lob.C.)' COUNTY OF LOS ANGELES BUILDING AND SAFETY '
Policy�No. � Compony �
O �Certified co s hereb furni5hed. . - BUILDING�o�33 � E � � -
Pv' v FOR APPLICANT TO FILL IN nooa¢55
� � Cerlified cop'y is filed with the co�nry building inspec- '� BUIIDiNG . ,
fipn deporfinent. . ADDRESS �
Date�• Applicom ' CITY D7 LOCALITY
� CERTIFICATE OF EXEMPTION FROM WORKERS' � - NO.OF BlIX',5. NEAREST. . - . .. . . . . .
� ' � COMFENSATION INSURANCE' � S4E OF LOT nIOW ON i0T CROSS 5T.
�This section need nof be completed if the permil is for one ASSESSOR �-
hundred dollars(5�00)or less.) .. TRACT BIOCK lOT NO. Mqp gOOK PAGE PARCEL .
TE�' U ZONE 1N+P
I certify that in ihe performance�of Ihe work for which Ihis OWNER � ' NO. �� � � � r
permit is issued,I shell nof employ any peison in any manner ,� SPECIAL a
so as�o become s�6jec110 ihe Woikers'Compensafion laws. �� ADDRE55 � � - � � �CD CONDITIONS 'y
. CITY . 21P . . .. . p�
Dote ' � Applicanl � qRCHITECT OR TEL. �
NOTICE TO APPLICANT: If, after making this Certifi[ate of ENGiNEER NO. DISTRICT GROUP TVPE FIRE PRO ESSED BY F
Ekemption,�`you should become s�bjecl to fhe Workers' " � CONST. ZON V
Compensarion provisions of the lobor Code,yo�must forlh- ' -3. y
ADDRE55
wiih comply with soch provisions or this pe�mit sholl 6e � '�
' TEL $TATISTICAL CUi551FlCATION APT. CON00. 2
deemedrevoked. ' ' � �� " CONiRnCTOR NO.
UCENSED CONiRACTORS DECLARATION - �i�, � CtA55 NO.� DWEII.UniiTS _
I hereby offirm ihal I am licensed under provisians af Chop�er 9 ADDRE55 NO.
(commencing wilh Section 7000)of Division 3 of the Bosiness ond . _ ._ . ���, ��R�P ' '
P�ofessions Code,and my litense is in full force ond etfect. CITV C1A55 BK. � VALIDATION �,
. SQ.F NO.OF NO.OF CHECK
Li[ense Number lic.Class � � � SRE S70RIE5 fAMIlIES ONE .. . . ,
, • ' ' N� SALUATIO_N, �O C/3 t�'A • �
COntra[lor � Dote � � DESCRIPTION OF WOR ADD ❑ Z) . .
�I om exempl under Sea . - � , - +�• • •�•�; --
ALTER ' • •Q���
B.BP.C.for this reason .. . REPAiR � f �
. .. Dale: � � EX ST�iNG BtDG (. �I, `i . � DEMOt ❑ . • • �+..==�=�
- APPLICANT F '1,r EL
..Signotdre �� . .. . . ... ._ PR�Ni -�� o. 5' FINAL . �,J�2����
OWNER-BUILDER DECLARATION DATE � �
1 hereby affirm�hot 1 am evempt irom tha CoNractor's licensa !,', .r. � , .
law for the following reason(Se2tion 7031.5,Business ond AODRE55 FINAL�
Profes ions�ode): � ' -� ��� - - � vkeseNi BY C
BUILDING w
�I, az awner of the properly, or my emplayees wilh ADDRESS U'� '
�woges as their�sole compensation,wi�l do ihe wo.k ond , - � -/rr' � �
the svuc�ure is no1 iMended or oflered for sote(SeUion ��titt � � �
�� � 70<4,Bvsiness and Pro�essions Code). � ' MOviNG �- --'- -- �TEt.-- /� ��� -- - � � � � �� - �
� I,as owner of ihe property,am extlVsively toNracling CONiRACfOR NO. ',y�.�'/ } +1 ,
�wiih Ilcensed con!roctors�o consrrucr�he project(Sec- - -� -�-� � � �� ��-- - �Y - —V ----- - .
tion 7044,Business and Professions Code). ADDRESS �� _^/7;� �.
__._ .._ REOUIREU. IUTALSEiBACKFRUM XI i. �' _ .�7IV_. .. .� .. . ... _. .. .
���CONSTRUCTION IENDING AGENCY-'"----- - "'- �i gp�K YAR� HwY PROP.IINE N/IDTH �� ���
I hereby affirm that lhere is a construction lending agency for FRONt ' � �' ' �
-Ihe performanm of the wark far which thie permil is issued -- P.L -- -- - - --- -�� - -- -- - �,� - � -� �� � , -_ ,�� •
�Sec.3097,Civ.C.). SiDE
`� - _. . . ._ .__... . _. . _ P.L. . . ..
� lender'sName - � --� � -- - -� --- - . . .. .
� y� LDhM Re4,# '
� Lender's Address � -� - P.C.Fee S Permit fee- ' -- � ;�
� ..
'" J certify that I have read Ihis opplicalion and slate lhat Ihe Iseuonca Fea - LOMA P/C M - - - -- _ . .
a abova information is correct.I agree b mmply wi�h all Counly �r in�esngm�on Fee '
$ ordinanCes ond.Slole lows relating fo building canslruclion, y� - -� Torol Fee� � � � �LDMA Perm.N -- � - � �- '
u
and hereby authorize represenlafives of this County to enler +'' �
$ upo tha a ve-meniioned property for inspec�ion p�rposes. � .
-- �2{YJ�p-( E J � �e�� - ' - -� - ' ' .
a ���f��`'�,r^}.�iy,yX'f�"*'�f, ��p�'�f�-�F ,��J SEE REYERSE FOR E%PLANATORY LANGUAGE
� �� nl A ent..
'- -S�gnaNre of Appl g Da�e . . . . -- .
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