HomeMy WebLinkAbout1130A 1292A (5) WORKERS'COMPENSATION DECLARATION
I lnsurebor�afcertlfcatteofWorkesr'Compensafoninsuronelf APPLICATIQN FOFt BUILDING PERMIT �
�a certifie mpy there f llSec.38 la��.�,,.
�'� �.`� �y��&� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No:"'l l O I ompany � � � ��� ,
,_ � Ce�ti4ied mpy is hereby furnished. � FOR APPLICANT TO FILL IN ADIDRE55 ��,.`_S��r �� C:1\+`
� Cenified copy is filed with�he c unfy bu'din �nspec- BUILDING f'L C'" '�, (• �A�� `�
tion deparfinent. 1 ADDRE55 � �� �' b� � r
t7 , �
Da+te�r�Appliconi+ CITV ZIP �Cc%� LOCALITY ~c G�*�"a C�F\ \�;"
,i�J i��^CERTIFICATE OF EXEMPTION R M WO CERS' ' NO.Oi BLDGS � NEAREST 1 �
1� "'1 COMPENSATIO U NCE SizE OF tOT a L. /�V NOw ON iOT CROss 5T. , ��Js�.._ ��._
j(T is se�[tion need not be mmple e if the permit iS for one TRACT fi� �� BLOCK LOT NO. t.L� MqP BOOK PAGE PARCEL
hundred doilars($100)or less.) �"�
M A n,� • TEL�.-!'� iy USE ZONE OP ^ � � .
I certify that in the perfarmonce of the work for which this OWNER I��+a.L.�r � NO.�"i `d d3 }
permlt is issued,I shall not employ ony person in any manner f SPECIAL p,
so as to 6ecome subjecr to the Workers'COmpensation Laws. ADDRESS ��^ � �a Y��LS CONDITIONS U
� Da�e Applicant CiTv Li,'Cki�N l.� ziP �'�1 �j� �.
ARCHITECT OR , TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: I4, after making this Certificate of �,jA'�(;�lL;�.S� NO. CONSLzU}-�—�� ZONE n M�
Exemption, you shou�d become s�6jecf to the Workers' ENGINEER
� Compengption provisions of the Labor Code,you musf forth- qDDRESS S�''u �.� „ ` -'-'"�-� 1 °��*=7-�'� ��,
� with comply wi�h such provisions or this permit shall be i: TEL STATISTiCAL CL4SSIFICATION APT. CON�O. CA
� deemed revoked. �ONT2nCtoR �(.Ai���`�'Li No. e�
�, LICENSED CONTRACTORS DECLARATION ���, CLA55 NO. �WELL UNITS !'�
I hereby affirm that I am licensed under provisions of Chapie�9 aDDRe55 tv0.
(mmmencing wi�h Section 7000)of Division 3 of the Business and ��� SEWER MAP
Professions Code,and my license is in full force and effect. CITV CLA55 BK � VALIDATION
$q.FT. NO.OF NO.OF CHECK
,r�icense Number 1.�'3 7 2� Lic.Class� SIZE STORIES FAMILIES ONE
�� y� 3� �� Ve1lUATION
� DESCRIPTION OF WORK � ���y,(� NEW ,�
ConVaUor Date App ❑ S �d �C3�
�I om exempt under Sea ���l-c1%��' �Ey"�"' ❑ / '�� � .�i il(�,
` A!TER e a
\ B.BP.C.for this re son q REPAIR � S ��° °�-�
` �°��'�'�""'�'� EXIST�ING BLDG. C� �EMOL � ,� �(� 1 (`
APPIICANT • ;El. �
Signature PRINi �.0 ��.(�1/�:LwvNO. �Q �Gv FINAL/ m a a F(i
� O NE -BUILD R DECIARATION DATE�-'f _ � � 9�'
I hereby a that I m exempt from the Contractar's License L- /
Law for the fo g reason(Section 7031.5, Bosinase and /aDDRE55 -��-'�';' FINA "� � �&.C;:-F;�
Professions Code)� � vRE EN BY
ggg ❑ BUILDING —
� I, os owner of the praperly, or my employees with ADDRESS ' �,�1_L�!f1 �
wages as their sole compensation,will do�he work and G" `�
ihe slrucfure is not intended or offered for sale(Section IOCALITY �
� 7044,8usiness and 7rofessions Codei. MOVING TE�.
� I,as nwner af the properly,am exclusively canfracting CONTRACTOR NO.
� with licensed conhactors to cons}ruct the projeU(Seo pDDRE55
tion 7044,6usiness and Professions Code).
REQUIRED TOTAL SETBACK FR
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE W�DTH
I hereby affirm ihat there is a construction lending agency for FRONT
ihe performonce of ihe work for which this permit is issued P,L.
(Sec.3097,C��.C.). SIDE y 1`
�"�q P.L. � I C C G It
g! Lender's Name LDMA Ref.#
i m P.C.Fee$ �� Vermii Fee ' �� `' ° �� '� �
f � Lender's Address ,
� '� +'%4.(�,'
� o I cenify 1ha1 I have reod this opplicalion and state thot the Issuvnce Fee LDMA P/C N m V
above� otion is correcr.I agree to comply with all Counly Imestigation Fea
ordma ces and State laws relaling to boilding constr�ction, Total Fee �DMA Perm.# °�������5��
/J and h e aut rize re�Jjesentatives of this CouMy to enter
��upon abov mentioneH property for inspection purposes. �8�J� -`a 8
�m $ '?j�r�� SEE REVERSE FOR EXPLANATORY LANGUAGE
€ Si notu of Applimnt or Agent Date
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