HomeMy WebLinkAbout1423A (15) � � .
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WORKERS'CC��MPENSATION DECIARATION µ � ��, � �
I hereby affirm ihat I have a certificate of consenl to self APPLICATION F�R BU � �
insure,or a ceni(icote of Workers'Compensation Insvrance, ���I�
or a certified topy thereof(Sac.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY �
Golicy No. . Compcmy �
❑ Certified co is hereb f��oi.t;ad. FOR APPLICANT TO FILL IN euaou�� ,
pY Y ADDRE55 ZOBOG /CpCK jr PO/�T/�%V. .
❑ Certified copy is filod with the co�nty building inspec- BqppREu aOBO /?Oe�ry poin�T�N. �
lion department. .
Data Applicant aTv W/1WGr'TCPOSTi!{.) na 9/789 �,��rv W.4L�u7' I
NO.OF 8LDG5. NFAREST I
� CERTIFICATE OF EXFMPTION FROM WORKERS' � SiZE OF lOT NOW ON LO7 CROSS 5T. /P�49r�f'ees"A}�--
COMPENSATION INSl1ttANCE� i
/ �?-� ASSESSOR ! '7
(This section need n01 be complBfed if the parmit is for One TRACT 37(7 BLOCK LOT NO.�/ - �y�p,p gpp� �Qp pq� �z� PARCEL �
hundred dollars($1W)or less.) TEL Ti¢ O
owNea�AzUY[!Kf /SN/.//�vIA NO. 2 �EZOI`ff �M1AP
I certify that in the performance of the work for which fhis r � ��
parmi!ia iasued.I shall not ampby.ony pereon in any manner AD�RE55 2O8O�m /�C�' pQfj{/'T LN� SPECIAI � }
CONDITIONS d
so as to becoma su6ject to the Workera Compensation iaws. O
� C4TY WA'�I{�(/T ZIP ��78y . . . V
Data Appliconl . pRGH1TECf OR TEL DISTRICi GRWP NPE FIRE VRpCF$$Ep BY �
NOTICE TO APP�ICANT: If, afrer making this Certifimte of ENGINEER NO. �Q�T ZONE �r
Exemption, you shauld bewme subjed to the Workeri � 2 �� c�
�Compansation provisicns of the lo6or Code,�you must forth- ADDRE55 � � �� �++
with comply with such provisions�w thia permi# shall be tE�. STATISTiCAI CL4551fICAT10N qpT. GON00. N
cleemed revoked. CONTRACTOR NO, - Z
LICENSED CONTRACTOR$DEUARATIQN . �C [3A55 NO. � DWFi1.UNiTS
I hereby affirm thm t am ticensed undw prOvisions of Ghayter 4 AO�RE55 NO.
(commencing with Sectipn 70pQ)of Division 3 of the Busineu LIC. 3EWER MAP
and Profassions Coda,and my licensg is in full fqce and.effett CIIY Cu55 gK � VpLIDAT{ON
SQ.Ff NO.OF NO.OF ' COH EK
License Num6er �ic.Clau - --� �� � STORIES FAMIUES
� DESCRIPf10N OF WORK � N�, � VUVATIpN
co�f�a�,o� oo,a : �! n a -
❑I am exempt under Sec /'fbA'77�/V OF dN�RCO!✓f �� � �
CFAM�L j� RO�M ALTER ❑ z�� D Z�A �
B.&P.C.for this reason REpA1R❑ ;
Dme: use oF fiiilaG6 F+RNI/t
EXISTING eL�G. Y�YBLLJ�Nf� D�p�Q ����i�t i
SignaWre APPLICqNT h T/ � ._..
OWNER-BUILDER DECLAR.4TION (PRINT)�/1Z4yU.r% /,r/,Nk n� _ ��� p�� ,� �L I���9 3.�O
I here6 affirm thot I am exem t from the Conrracror's license =�
v P AODRE55�OBOG �Qpc(�y��.N, a�fr�iVu7• ��n��J� r •'9 3 0 0�
law for fhe fo4lowing reason(Secrion 703}.5, Business and N �
Professions Code): . . . . . . . PRESENT By � �Q,,� Q—$9
� 1, as owner of iha proparty, or my empbyees with p�p�E�S Nl
wages as their sole compenaation,will do Ihe work ard i�iiry �
rhe strudure is not intended a offered for sale($ection � r
7044,Business and Wofenions Code.} MOVING iEt. ' - f
❑ I,as owner�of the property,am axclusively controcfing COMRACTOR NO. . �
with IitBnsed[OMmtlOf!10�tOneirod fhe projett(SeC- ADDRE55 � � � �
tion 7044,Bualness and Professions Code.)
CONSTRUCTION LENDING AGENCY - SET BAEK - �ARD -HWY TOTAISETPAAC1cEF� WID7H �
I herehy affirm�hat there is a construction lending agency for FRONT �
ihe parformanca of 1he work far which thia permi}is issued P.l. .
(Sec.3097,Civ.C.j. SIDE � -
P.l.
lender's Nome
� . . .. . 4.... IDMA Ret.R
P.C.Fee S Permil Fee i
� lender's Address �
I cartify thot I bove read this applicalion and stafe fhat fhe � Issuonm Fee LDMA PiC M
gabova informatian is correct.I agree ro comply with all County Invesngarion Pee . •�,/� ,
� ordinances and State laws relating to building construction, � romi Fee � (! LDma Perm.N
� ond hereby authorize representatives of this County fo onter .
upon the a6ove-ment/ioned/property for inspe[tion purp es.
� ���,�—.(i-��f�, ¢ �� B SEE REVERSE FOR EXR/1NATORY IANGUAGE
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