HomeMy WebLinkAbout1069A 1070A (9) WORKERS'COMPENSATION DECLARATION 'I
1 here6y affirm thot I have o�e«;f��a,e ot cansent fa self APPLlCATION FC?R BUILDING PERMIT �s
insure,or a certificote of Workers'Compenstion Insurance,o
a cer�ifie co rhe f� � saao,�ab.c.� COUNTY OP LOS ANGELES BUIIDfNG AND SAFETY
Po���i��������y BWIOWG --� �:+
� Cer�ified copy is hereby turni:hed. ' fOR APPLICANT TO FiLL IN ADDRE55 �'1 LP
Certified copy is filed with�he munty 6uilding inspeo BUiIDING `� �
tion depoAme�t ADDRE55 � LOCAIITY �
NEAREST
Dai��� Applicom . �r CITY 2iF CROS55T. �J..
V�� NO.OF BLDGS. ASSESSOR
� CERTtfICATE Of EXEMPTI N FROM WORKERS' SIZe OF i0i NOw ON lOT MAP BOOK PnGe PARCe�
COMPENSATION INSURANCE USE ZONE MAP 7 e� �p
(Fhis section need not be mmple�ed if the permit is for one TpA�T g �Vi NO. ' No. �Q U / � !vp 3� Y
huadred dollars(S��)ar less.�
� � TEL. SPECIAL p,
i cerlif rhaf in the erforma�ce af�he rk for which rhis OwNER ! O 't' i�� CONDITIONS �
Y P / DISTRICI GROUP TYPE FIRE PR ED BY V
permit is issued,I shall not employ o erson in ony manner ^ CONS7 ZONE
so as to become subject to the ' ers'Compensa�ton taws. AO�zE55 ! � !�P �'L7 `O ,{�---� � 1„ (� O
� n b `1�L� �s,�� \��
Date q i�onl arr
STATISTI[AL CLASSIFICP,TION AFT. CONOO.
ARCHRECT OR ,r.!+ .TE�� Q�'K W
NOTICf TO APPLICA . If, ofrer mokinq ihis Cenificote of ENGwEER �� �+ . �UA55 NO. DWELL.UNITS_ fL
Ezempfion, you uld betome subj�cl to fhe Workers' p �� VI
Compemation visions of Ihe Labo*Code,yau mu5f forth- qDORE55 7 �� � ' t� ��'NER'�P z
with compl ith such provisions or this permit ehall 6e _ T
deemed r oked. COtvtRACTOR Na. BK, PG, VALIOATION
LICENSED C4NTRACTORS�ECIARATION � tK. �� ..
I her �y aFfirm fhat I am Gcensed under provisions o4£hap�e�9 AODRE55 7 � �' YAIUATION
(mmmenting wi�h Section 7000)ot Division 3 of the 8usiness ond / . " .,
Professions Code,and my license is in full iorce and effect. CITY / CLA55 s3,o0 o pL�Q 6 9 A
�Q SQ.Fi O.OF NO.OF CHEIX �
Cice�se LiG C{a53 �J SIZE STOR�E$ FAMIUES � ONE
� s #•�••23
�ESCRIMION OF WORK NEW
CoNraci ' Dare � � ADp � ! •�2 3 2�
❑ ' �+ �+'
I om exempt from ihe licensing requiremenfs as I om a AL7ER � FINAL 'Z�'�Q=
licensed archi�ect or a.egisteied professional engineer DATE�'� /"S�— ��� "
acting in my professionol capaciry (Sec�ion 7051, yC� ��� Q REPAIB ❑ �
Bosiness and Professions Code). USE OF ��� � FIN �2� 8�S'�
EXiST'�NG BLDG. � �
Lic.oi Req.No. Dole AGPLICANT • 1 TEI. Br ��O Z O A �
OWNER-BUIIDER OECLARATION (vRM71 / �(, NO. i
I hereby affi�m�ha�I am exempt irom the Coniractor's license l � /��� - ���� ��� I
Law for Ihe foll owi�g reasan(Section 7031.5, Business and p��RE55 �- J I��- r%r.s' � n'- t �l�/t / //�7 � //�
Professions Code): PHE N7 �(��/�_ ��z-j„ �/I C Q.a... �.[►w g'l r���3 7,5 0
BUILDING ( � Yt�x
� 1, os owner of the prpperty, or my employees wiih A�DRE55 YI • � �3 7.5 a�
woges as their eole rompensation,will do the work and �aA�liv p��Q ���'� 1n� /�
the strocture is not inrended or offered for sale(Sec�ion A^"' lri�`-t��2� 8�a�
7044,Business ond Professions Code). MOVING TEL V
� I,os owner of the prope�ly,om eadu5ively controcting CONTRACTOR ND.
wiih licensed contractors to conslruct f e project(Seo- qpDRE55
tion 7044,Business and Proiessi oda).
REQUINED �TOTAL SEi6ACK FROM EXISi.
CONSTRUCT�ON ING AGENCY SET BACK YARD HWV pROP.L�NE WIDTH
I hereby aFfirm thol ihere is consrruction lending agency for FRONT
�he performance-of the ork for which�his permit is issued P L �
(Set.3097,Civ.C.�. SIDE
P.l.
Lender's Na /�,
$ P.C.Fee$ ��, O Permn Fee `7
Lend s Address
W ertify thot t have read ihis application and state that rhe issuo ce Fee l
aabove in4orma�ion is correct.I a e to comply with all Counry in�esugarion Fee n � �
$ ord�no ` �e Iaws r ng fo building tons�ruuion, Total Fee�_
� o ereby authori e pre atives of this Coumy to enter
m Pa roperly fo inspectiAon purposes.
� /y_/�'/ - 5EE REVERSE FOR E%PIANATONY IANGUAGE
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