HomeMy WebLinkAbout1553A (439) WORKERS'COMPENSATION DEC�ARATION � � �
� -•1 hereby affirm that I have a certificate of consent to Se�f qpp��CATION FO�t BUILDING PERMIT �
insure,or a carlificate of Warkers Compenwtion Insumnce,
w a certified topy thereof(Sea 3800,lab.C.) COUNTY OP!OS ANGELES - ---- - BUiIDING AND SAPETY
Policy No. � Compan�r
❑ Certified co is hereb furnished. FOR APPLICANT TO FILL IN BUR°�NG '9
PY Y AODRE55 �3�O `�L I��O �. � (/
❑ Cehified copy is filed wRh the couny b�ilding inspec- q�pouEs�s I3�0 E.VRLL 1i�sT�pRiYE ���,
tion department.
Date npp��can� aTv DIRMONI7 � zir �av.0
NO.OF 8tOG5. NEAREST
CERTIFICAlE pF EXEMPTION FROM WORKERS' SIZE OF lOT NOW ON l0T — ��q 5
COMPENSATION INSURANCE ���
(This section need nm 6e completed it the permit is for one '� TRqCT '3J�s'�� g�p�K - LOT NO. � - /�qp gppK--------- -- -- pqGE PARCEL
h�ndred dollan(SIOOy or lesc,) owr�R�Y,�+41..C'�W� ,� np�Ll�(a13�103(� usE Zon� Mnv
I cartify that in Fhe performance of ihe work for which this r�o. ��-33
permit is iss�ed,1 sha�l not employ any gerson in ctny manner AUORe55 Q>�'$w• s�"i.'�7� � ���A� - a
so as to become sobject to rho N/orken'Compensation taws.
�No�T�� �P3 3 0
ciN tos�tC��t�s c� ZiP�►7 v
Dpte Applicant ARCHITECT R 7E� � �
NOTICE TO APPLICJSNT: If, o6er moking lhis Corti{icaTe of ENGINEER � {,(N ��� DISTRICT GROUP NPE E PROCESSED BY �
Exempfion,-yo� should become su6ject to tFre Worken' c� / �j �ONST. Z �
Compensofion provisions of ihe La6or Code,you must fwth- ADDRE55 ��Y+�W'1 5'�'.w.P�Sf�O��g�� ����f� (J� �I N V
W
winc �omply wi�h such pro�isions or rhis permit shall be rEL STATISTICAL CIASSIFICATION r coNop, '�
deemed revoked. COMRnCtOR��R�(W1 Cpnip, Z
� LICENSED CONTRACTORS DKLARAiION uC. CwSS NO. �'S DWELL.UNITS
I hereby offirm thpf 1 am{icensed under provisions of Cfwpter 9 ADDRESS NO.
��� SEWER MAP
(commencing with Setlion 7000)of D'evisicn 3 of the Business C�n, ��
and Professions Code,ond my license is in fult forca ond eHect. gK, pG YAL{DATION
SQ.Ff�,` NO Of !I NO.OF CHEIX
ticense Num6er Li0.Class SIZE !i� � STORIES � FAMILIES ONE
OEXRIP�ION OF WORK�C�PS�S NEW � VALUA7ION
Conhactor pote � s. �'Q��p � �
❑I am exempt under Sec.
�,►-w„�,s'�4 A�
ALtER ❑
B.&P.C.4or ihis reoson f
u�� REPAIR❑
Date: E7(ISTING BLDG. DEM01❑
����� FINAL
S+gnmure (PRINT� OM LI(�IpS �Nopil$
OWNER-BUIIDER DECIARATION DATE ;. 1 �5'
i hereby affirm that I am ezempt from the Confraciors Licensa � . " ,..�
Law for rhe followl�p�eason(SeUian 7Q31.5, Business and AODRESS F� . � -
Professions Code): PRESEM By `' �'�-'�.�F�J
❑ I, as owner of the ro er BUILDING _
p p ry, or my employees with qpDRE55 - •' ' � - —
wages as tbeir sole compenaafion,will do the work and LOCALIN � � '�C��-�,""•^
Ihe Sfrodure is not iniended or offered far sale(Section " - •
❑ 7044.Businwc and Drofoaw�e Code.) . sAOv�tdG TEL.
I,os owner ol ihe property,am exciusively conhocfing �NTRACTOR NO.
wilh licet�sed[ontraciots fo construd the projeci(Seo- AD�RE55
tion 7044,8usiness and Professions Code.)
,REQW RED IOTAI SETBqCK FROM�� FJ(IST.- •� /) �7 .�
CONSTRUCTION IEN�ING AGENCY �j gq� YARD HWY pROP.LINE ��� n�� �
I hera6y affirm ihat there is a construtlion lending agency for FeOhli Wy�,�jk a.�,�i
the performance of the work for whlch this permit is issued P.L. -� r
(Sea 3097,Civ.C.). SIDE �
P.L.
Lender's Name �
m t� . . LDMA Ref.
P.C.Fee S I/� .�o Permit Fee
� Lenders Address ,
o I cartify that I have�ead fhis opplication and state ihat the M� 60� � iss�ance Fee LDMA PiC M
$ above information is correct.1 ag�ee to comply with all County imeatigorion Fae
R wdinonces and Staie laws relating to building construction, Toial Fee IDMA Verm.A
� and hereby authorize repiesentatives af fhis County to enter
g �pon the obove-mentianed property for inspecfion purposes.
� SEE REYfRSE fOR EXfLANA70RY LANGUAGE
� $ignature of Applicanf or Agent Dole
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