HomeMy WebLinkAbout1553 0030A -' WORKEkS'COMPENSATION UECLARATION �� J �
, . -� �e,abY affirm that 1 hove a�a.,� , o�o���o a APPLiCATiON FOR BUILDIiVG PERMIT
insure,or a certifica�e of Workeri om n tio nsusa ce �
o�rq�ce �fied copy Ihereof(Sec C .
/y� p�� q COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poliey�y`a/11�,�pFnpany .
❑ Certified copy+s��t �: d ' . FOR APPLICANT TO FILL IN BUILDING /�
� ADDRESS �[ � /UA •
Certified copy is k it e u d B NG ^� �1 ,1 f
tion depaRmeM. ADORE55 'J �/ y �� 7� �� �
DcN `�f I-9J APPlicont Giv DA11� $A��2- � z�P toCaurr
CERTIfICATE OF EXEMPfION EROM WORKERS' NO.OF BlDGS. NEAREST
COMPENSATION INSURANCE SIZE OF l0T NOW ON l0T CROSS ST.
Thia seclion ne�d nc1 b�com tet�d if ths rmit is ftt one Q ���
hundred dollafs(5100)or IBSs.) � TRAtt -1 BLOCK LOT NO. � /�qp gppK PAGE PARCEL
iEt.�l1i US�.I.ON.e.: J
OWNER � �GL GO NO. �j�ID�. - ��' ��/ � 3
I certify thot in ehe performance of the work for which this ' NO. "���x�t =3
parmit is issuad,1 ahall not employ any person in any mannm �D�� _.� �1 ST ��l.n SPEUAL � - , . . O,
w as to become aubjec�ta the Workers'Compeneation Lawa. ��� � CONDITIONS �8 2—
cirv I.aS-Ai•� �t�'si G► iir -19D4t� v�
Doto Applimnt � ��
ARCMITECT TEL.
NOTICE TO APPLICANT: If, after making this Cenifita�e of ' �� � 7Q�' WSiRiCi GROUv tvPE FIRE PROCe55Fn BY O
ENGINEER
E�emptfo�, you should baeome sub�eef �o ehe Workers' �t( e� �� Z V
Compenwtio�provisiona of the Labor Coda,you must forlh- qDDRE55 qi� F� S , �O. � � ld•d7 �-Z. � W
with camply with such p,avisions w this permit shall 6e �f� ��"� p,'
deemed revoked. CONTRACTOR �L- �O��Q�.r.Np. 3 ���$y� STATISTIG4L CtASSIFIGTION A7T. , fn
LICENSED CONTRACTORS DECLARATION �'r Z
�y� �rc, C1A55 NO. OWELL.UNI75
I hereby oKirm Ihol l om licenaed unde`provisions of Chaptet 9 ADDRE55�1� {j.�r * � #��O Np, $EyyER MAP
(commancing with Sedion 7000}of Division 3 of ihe Busineu and A ���_
Profeasions Code,and my license is in full twce and eifece CITY !+N E � MSS y��ppT�
Sp.fT NO.OF NO.OF � CMEGK �. �'.
Li[ense Number ��1�S� �i�.[�ays � 52E STORIES � FAMI IES ONE
Icow �.��c7'ro�/ S-3/-�'0 � VALUATION � # /S33
GonlrOCtor �1e DESCItIPfI OOF W� ��D ; O O� O Q 9
ApD b
�I am exempt under Sec. ���
ALTER �
6.8P.C.for this reason � f
REPAIR ���yr��
Oofe: U�� �
EXISTING BIDG. �� ❑
Signature APPLICANT TEL. FINAL
1�r�-
OWNER-BUILDERDECLARATION PRINT NO. DA7E l0-31-4o y'�
t herpby affirm�Mt J.am exempt f�cm the Convactar.'s Licensa
Law for the fo�lowing rcason(Settion 7031.5, Businesa ond /+DDRESS FINAL
Wofassions Code): i�
Q . _ 9U�LD�NG .
I, as owner of the propany, or my emp�oyees with,�, qpot�SS • ��•' �C L�r,�,
wages aa their sole compenwlion,will do the work ond�� . ��
the structure is not intended or offared for sale(Section ��1t7Y - - -. - �� - � , � �. � � _.
7614,Buairtess and Profeuione Code).- - MOVING TEL � h P f 3 °c�
� I,as owner of fhe property,am exclusively com�aSt�29 C TRA6TOR •� : ' NO. � .-
with licensed conhae�ora�o tonstruct Ihe projecl{Sec- .. ` '",•�'°�-' ... ���,. 1 r"��•i. 2 z�5 3 2 1 3
tion 70d1,Business and Profeuiona CadeJ. ADDkE55 , � `^
REQUIRED TOT.rLL SEtenC[ �G:,v C ' �_
CONSTRUCTION IENDING AGENCV SET BqCK ��� �WY PItOP.LINE WIDTIi
I hereby affirm that there is a construction lending ogency for FaONi � �.C c<`U G
the performance of the work for which this permit is issued V.L.
(Sec.3097,Civ.C.�. SIDE
v.t.
Lender's Nama
h�, , IDMA Ref,tl
m lender's Address P.0 Fee E Parm��Fee aC '
� I certify that I have read fhis applicotion and stole thal the lssuan<e Fee �3•�� LDMA P/C M
pbpve informolion is Fwrecl.I agree to tomply wilh all County �nveatigation Fee ` �r
ardinan s and Sta�e laws rela ing to buiiding con:truction, Toml Fae D 1;y
and 8 by authorize repre al�vea ot fhis County fo enfer �v�•/ � ���Perm.M �
up e abo -meMioned p pery fo " spedion purposes. �
SFi IIEYFRSE fOR F7(PtANATORY LANWAOF
� Signalurc of Applicanf rn Age� Uota
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