HomeMy WebLinkAbout1315A , .. _ ... _ __ .. _ ----.__. _. - -- ._ _ _... .
� WORKERS'COMPENSATIONDECIARATION . � �� �
I hereby affirm �haf I have a certifiwte of consent ro 5e�f � APPLICATIQN FQR BUILDING PERMIT �
insura,or a certifica�e of Wakers'Compenaolion�nsurance,
-- --- - - - - -- -- - - - -
or o certified copy rhereof(Sea 3eoo,�ab.C:) � - COUNTY OF LOS ANGELES BUILDING_AND SAEFTY
Poliry No. Compony � ��� �
} ❑. Cerlified copy i:hereby furni:hed.- � . FOR APPLICANT TQ PILL IN J a 9 0�
� Certified wpy is filed with the counry buifding inspec- BUILDiNG //�
tion depariment. � ' ADDRESS � G� ��`" �V� �
� �/��'`� . ,. .... _._........... .. ........ _ . .. ,.... . _ . .. ..... . ... ._. .
Dote Applicant CrtY ��V V 1 ZIP LOCALITY
� .CERTfFKATE OF EXFMPTtOM'FROM WORKERS . . . ... nio.oFeiuGS. ....----.... ._ nFakESt '
• ...C�MPENSATION�NSURANCE -- � S12E OF LOT NOW ON LO7 CRO55 5T. �
(This section need not be`comploted if the permie is for ona � -- - - -- - - -- .^} �R - � � �' i
h�ndred dollors($70�)oc less.). TRAQ � � BLOCK LOT NO. ��/- µpp gppK- - p,qgE PARCEL I
TEL USE Z�NE N�O O �� } I
I certify that in the performance of the work for which�his �'�'�'�ER p-�77 �^N NO'
ormil ia issued,I shall no1 em lo an rson in an manner C ,/ {� �r �� SPECIAI - � �
oc to beFome subject to the Worker Compensat/,o�/Jni9'ws. �DRESS ��,vt Lld7 'V� ��� '} /J�� COhWRiONS V
Date j'v- �6 Applicun s�-�"��+`�`��� - CITY (/V �F1'}�✓� ZIP O
NOTICE TO APPLICANT:�If, aflCr making Ihis Certi4imle ofi ARCHItECi OR 7EL. DISTRICf GROUP TYPE . FIRE SSED BY. F
ENGINEER NO. �pry$T,, Zpp�E `j I
Exemplion, you shauld bewme subjad to�Ihe Workers' . . --y �� ? �y I
Compensation provisians of the La6or Code.You.must forth- ADDREu / 7 �. _�`..._.._ ' .... - �.,,7 y.-• y
wi/h comply wilh 5uch provisiona or Ihis pBrmit sFwil 6e - - �--��-
�// TEL.[�p 7� STATISTIGIL CIA5S4FICATION APr. CONDO. Z �
(ICeR16d.revOk6tl. . . - � CONTRACIOR ��%��' NO..J/6��6�J .�l � �
UCENSED CONTRACTORS DECLARATION ' � '/ �K,� �� -Q.455 Ai(S.�*+ DWEtt:UNFtS I
t Aareby affirm tFwt 1 am licensed under provisions oE Ctwpter 4 - ADDRESS �.3� ��.'* 1• �. S�yyER AMP �f
(cor�mencing wit6 5ection 70W}oi Pivision 3 of"the 8usiness m�d __ . .. . . . p�, . - {
Professions Code,and my license is in full force and effect. �iTV � C/ ��---i-� /�` UASS Z-' � � ' VALfDATWN i
_ .� ��y $p.FT:.._ . NO.� NO.OF CHECK
I.kense Num6�r ic,Class" -� � SIZE 570RIES FAMILIES ONE • �
- viuu�rron � .
��� �6 ---- o�scRiv�ior+oewoeK - - rJ �
_ _ — _- - � S �
Contmctor 9 te� S U
� �3a`7 �"y� noo �
I om ezempt under Sec � /?��7 �
ALTER
8.8P.C.for this reason � �-- REPAIR � s
. . _ ._.. - -Date:-- �/�/���,,�/J I
-- USE OF //!/�7�-+f..s/IG�" �+O
. � E%ISTING&�f'i. I i
_.
_ .Signotwe ••��. �� �ct�a—� APPIPRIMT NO. FINAL +�/�y
NER-BUILDER DKlARATION , - - _--DAiF���i--/--�-- -
.J harobyaffi.mahatlamsxemptfsamt}w Coahaclor'slicense .
Law for the fdlow'vg-reasoa(Secfion 7037.5,Busineu and ADDREu RNp� �
Prafeuions Code):.... .. .. ..".. . . .. -- � BUIIDiNG --- � BY f
--. t'i �.:1
� I� az owner of ihe propeny, or my employees with ADDRFSS .
wages as their sole mmpensation,will do ihe work and � �. , . . o • �
the siructure is no�intended or offered for sole(Section ����TM � - -
' '704�,Busln¢ss and ROfeaiorrs Code):"�. . MOVING � - i�. - n •" -
.�. I,a5 owner of Ihe property,am exclusively contmcting CON7RACTOR NO. ,_, � " � J
witb tiCenseC tontractors fo construcYlMe pra�ecf�fSeo- qDDRESS ' " � � � �
tion 7W4.Business and Professions Code}. "
.._ . . . CONSTRUCTION LEN6ING AGENCY ' . _RSET�BACK YARD HWY T07AL�LME WIDTH . . .. .. - -_ G�u,i..;_�s G'._
1 hereby affirm thaf�here is a construction lending agency for F�7 � I
fhe perfumonce of the wo for which�his permie-"r�isaued P.L. - - � i
(Sec.3097,Civ.C.). / /` SIDE i
� � . � �
P.L. �
Lendar's Name � �� _
� LDMA Ref.N
. . _ .. . -' - P.C.Fee S � Permn Fee - -
lender's Addreaa - .
�
� I ceAify.thof ihave read�his application and siate ThN the iss�nMa Fee 1 . J� - LDwv+P/C M � �
Q obove informotion is correcf.I ogree 10 tomply with oll County Inves�igo�ion Fee
ordinq.nces and 5tate laws relming to,6uilding construdion, . . To�ol Fee �. ��tOnM1A ie.m.M� �
u and hereby aut orize representatives of tAis Count ntar
� upon The o - emion property f pe ' paip es. �
c !�� /.• SEE REVFFSE FOi E%PLANATORY LANGUAGE
�.�..�.�..�Signahrta o4 Apptimnrw Agen� Dote - ��
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