HomeMy WebLinkAbout0711A 2802A (6) � WORKERS'COMPENSATION�ECLARATION �� ��'"�
'�1 hereby affirm Ihal I hove a certifimte of consenl fo self APPLICATION FO� BUILDING PERMtT �
insure,or a certificate of Workers'Compenwtion Insurance, .
a cerri da`d�co�p�y,p�h.e�eof Sec.3800,tab.C.) COUNTY OF LOS ANGELES BUILOING AND SAFETY
Policy�" " ��pOnY /1/� �ILDING y
�Certified copy�s hereby furnished� FOR APPLICANT TO FILL IN ��Q �
❑ ADDRESS 1
Certified copy�s filed with�he co�Ny buildin9 ins eo BUiIDING .i/D
��on deparfinent. ADDRE55 �
�a1e�Applicant Cliv ZIP IOCAIITV `\ �l�C���1r� �r�s�_
�RTIPfCATE OF EX N FROM NO.OF BlDGS. NEAREST `
� ����I� COMPENSATIOtJ INSURANCE SIZE OF LOT NOw ON lOT [R065 ST. S11JY_
(This sectian need not 6e cumpleted if Ihe permit is tor one - iRAR- - -� BIOCK "" LOT NO. � ��R
, hundrad dolloro(EIOQ�or leas.) Nu1V BOOK CAGE PARCEI
.. 7E1. ZONE h1AP
I certify thot in the performonce of the work for which this ��R N�O�� ��
permit i5 issued,1 ahall nof employ ony person in ony manner `��p� �
so as to bemma subjad ro 1ha Workers'Compenwtion lows. ��� / ���T�� �
CITY p ZI7 �
Date Appiimnf ARCHITEC7 O 1EL.
.' �TICE TO APPlICANT: If, afier making ihle CmRificaro of � DISTRICT GROua irpe ZRwEJE VItO[e55eo ev O
\ :mprion, yov shoold 6ewms wbjad fo rh� Wwkeri ENGWEER o. _�. � ,(� CON�,�
Compen6ation provisions of the L06or Coda,you muzt forth- qppRE55 O .�1 ��Z `� l� ��" 1 (�C W
with comply wifh such provisions or this permil shali be . TEI. S TICAt QHSSIFIUTfON AGT. CONDD. �
deemed ravokad. cowrRncrat np — n� Z
LICENSED CONTRACTORS DECLARATION ���, f1A55 NO.�DwEll.UNITS
�he�ehy affirm Ihat i am licenxd under ptovisions of Chop�er 9 ADIX2E55 NO.
(commencing wifh Section 70W}of DivisioN 3 oF the Businas3 a�d LIC. '��R�
Professions Code,ond my licenae ia in fuli forca ond affect. CIFY -�i CtA55 '� BK � YALI�ATWH
�.f $p. T' NO.OF �J NO.OF CME K
Li[ense Numbar a,���� Lic.Claa' ,�� SIIE S70RIE5 (r FAMILIES ONE
VAlUAT10H
OESCRIPTIOIJOF WORK �W
�o�,�,o,T%�,�� s,+Ir�o,a � s 1`a.�c�c�
p Terw,-►k rrr+ oF . "°° �
I om exempt undar Sec. � A��R �
��7L� A
8.8P.C.for thia reaaoo �xLS REPAIR - �
lJSE Qf �'. e?v
D f6: E1fI5TING BLDG. ' �E� � � • -
s�g�ow.a nrvuuNr. � a�3 pwu C I •5 C 3.6 3
WNEp-BUILDER D �iNi 1 De5 0. Z 6 DATE �!.�z,,�ip
1 hereby affirm thet I am ezempt r m fhe Mractar's Liceoae � " �" " " � �"� � "� � � "�� �� � 't
Low for the following reaeon(Section 7 I.S,Buainess and ADDkE55 pNu �--� • c J C�"�,`:`''
o�of��a��c�ar R �y o�.o G—��
� � BUIIDING
1, as ow�er of the property, or my empbyees with n0OrsE55
. woqes ps their wle tompensation,will do ihe work and
Ihe shuclura is not intended or offered for cole(Section �O�AUTY
704A.Business ond Professio�s Code{• MO��� i� . - ..
� 1,as owner ofi the property,am exclusively controcfing CONTRACTOR NO.
wi7h 4icensed contmclan to conatrucf!be projrcl(Sec- ADDRE55
tion 7041,Buiiness cnd Rrofess7ons Code).
CONSTRURION LENDING AGENCY 5�T B qK YqRD HVJv 707AL�tvB,4`INE wIDTH
1 hereby affirm tha�there is a conslruclion lending agency for FRpry7 z 2 8 0,2 A
the perforrtwnce nf lhe wwk for which this permi�is issued v,L. ��� � � ��
(Sec.3097,Civ.C.). SIDE
P� I ••60,OC
lender's Name
O lDha Ref.M I •�4���
m P.C.Fer S Q P�rmir Fw
` Lender'a Addreu (��yf
� I certify that I have read this appliention and slWe IhW�he iaauonce Fee IDMA P/C N v 1 1� , ••6 C 3.;��
� o6ove informotion i�cortetl.I aqree to comply wilh all County Inresii otion Fee �y
� q ordinontea ond Slole laws relating to buildinp conatruction, � Tom1 hs a 3 � IDMYA Perm.k�0� � �.��—�8
ond hereby authwizs rap�asentofives of rhis unty to enter
� � upon the above-men�ioned p pe ty for in etion purposea.�/ \c'n M O O �(�mw e�s.O G
� _�/ ��D d�>]�•� J .l
fFiRiViNSE/OREXPUINATONY UNGUAGi
Siynatura of Ap �ate
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