HomeMy WebLinkAbout1395A WORK€RS'COMPENSATION DECLARATION �� : ' �
I hereby affirm that I have a certifiwte of�o�5e�r,a��f qpp��CATtON FQ� BUILDING PERMIT ��, ��
insure,or a cer�ificole of Workers'Compensation Insuronce,
or a certified topy thereof�Sec.'3800,la .C.) COUNTY OF LOS ANGElES BUILDING AND SAFETY �
P❑olicy No. CompcnV r• "'" � � ,
Certified copy is hereby-furnished.- FOR APPLICANT TO FILL IN �����' q f�
Certified co is filed with the tount tuildin me eo ADDRESS J� w/ �o� V� i
py y g� p BUIIDING � Q
� tion deparfinent: ADDRE55 W 1 r`� � �
`�� I
Dare��ApPlicam . - c�tt W�L�1 zIP LOCqI�m Yy �- , I
�RTIFICATE OF EXEMPfION ROM WOKKERS' � � NO.OF BtDGS. NFAREST p �7
� COMPENSATION I RANCE SIZE OF tOT NOW ON l0T CROSS ST. y_ O N �L�/ �
(This section nead not 6e complated if�tha permit is for o�e ��R ����
hundred dollars(UW)or less.) TRACT� � BLOCK LOT NO. � MqP BOOK PqGE� PARCEL
TEL. �/
OWNER I�G ��i NO. � E �,p, /��-�ea�
I rertify that in Ihe performance oF the work for which this � � " )
permit Is iuued,I shali not amptoy any pe son in any monner A�� ��9� ���A� - d
w os ta bacome sub�eci to fhe Wor ers' mpe tio Laws. p CONDITIONS u
.� � /"� . - . . .:.� GITY �11r V Y N ZIP �� �
Dote APp��COM ARCHITECT OR 1EL. O
DISTRICL GR UP NPE fIRE SSED BY
NOTICE i0 APPUCANT: If, after aking ihis CerNfitare of E�,�NEEB P10. ✓J µ57. ZON (~j
Exemptan, you should becom subject to the Workers
P P . Y ADDRESS �` L L- d
Com ensatian rovisions of the 6or Code, au must forih-
with comply with such provisions or this pormit shall be ------ -- .._ . -._ - -,l.. ......._.. ....�L. .
deemed revoked. � .. - � � CONTRACTOR �` � g �� STAASTiGAL CiPS�5;1�[iG/)aTION APT. CANDQ�-���
LICENSED CONiRACiORS DEQARATIOIV -- 4 p - itc.�j p- �5 nw. "'" �wEu UnUTS- -
I hereby affirm that i am licensed under pravisions af CFwpter 9 A�RESS�J d$ G +� NO.iJ� �� D
(commencirg wilh Section 70(10)of�ivision 3 of fhe 8usiness a� . �/ . .. ..11C.- _ �R�P . ' �
Profassiona Code,and my litense is in full force a�jn�d effeGL CITY 1'<<W�d� CtA55 C�� ��/���� y/UApqn(xd
. .� ���!O O -..� . �. .. �fr'�� 5(i.Fi. NO.OF NO.OF CHECK
license Num4er Lic.Class' S2E StORIES FAMILIES ONE .
� }�!y'h J(� VALUATION �
CoMrocfor�B�V_'�jf Dute �� DESCRIPTION OF'WORK �O � ; ��A 0.��
� � `e r' W � u �
I om exempt under Sec. �
ALTER
8.8P.C.for rhis reason REPAIR [� S
USE OF
- - Date: EXISTIIJG&DG. �� ❑
APPLICANT� � 7EL.
"Sigirotwe FINAI
OWNER.BUILDER DECLARATION PRINT .. NO. ..��,_ _�r�.�, : � ,'n t,�,.
1 here6y a4firm thot 1 am axempt foom 1he Cenuacwr"aLicense .- -
low for ihe followirtg reason(Section 7037.5,Bosinau and ADDRE55 - ---- �
FINAtuj-'"�_�-=- � n.: •s • •
'ProfesslonsCode): .. . . ... .. . _ PR . .-_ ._ -_. . .._ __.__. --gY .--i.fL� - . . .. -
❑.. BUIL�ING ' � < ��� „ ..
1, as owner of fhe property, or my employees with ADDRESS
�wages as tFei7�sole compensation,will do tha work and � �; ; , �„
the slructure is not intended or affered for wle(Section ����T� � , � -
7M4,Bvsiness ond Vrofessions Code). MOVING- � 7EL. �
� I,aa owner o f�he propeMy,pm ezc tusive ly con l r ac�ing CONTRACfOR NO. � il U. I � -C�-F � .
with�titensed tonrcotlors ro conshvct the praject(Sec- � qDOR�55 ..
tion 7044,Busineu and Professions Coda). , �
--- - - CONSTRUCTION LENOING AGENCY ��gq�K YARD HWY T�T pRpp�ME WIDTH
1 hereby offirm thpl there is o construction lending agency for FROM �
the perfwmonce of the work for which this permit is issued � - P.�.-� - -- � � �
(Sec.3097.Ci�.C.). SIDE ..
_ P.L. . _. . . _ .
$m Lender's Name ��� . �
IDAM Ref.N
- Lender's Address P���Fce S Permit Fee �
� I certif_lhat I have read this a licauon and_swte that ihe _ / 1� '
y pp luuance Fee J� LDMA P/C M
� nbove informatian is cwrect I agree b comply urith all County i�„esecqa��on fee , �
� ordinances and Smre laws relating io 6uilding construcrion, Toro�� ���b LDMA Verm.# '
'" and hereby authorize representatives of thia County to enter
� up ih bov ' a roperly��Inspeclion purposes.
� `/�� SFE REVEiSE FOR EI[PUNATORY UNGUAGE
�grioturo oi Appl�can�a Agent Date - - p'
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