HomeMy WebLinkAbout1595A (17) 1 WORKERS'COMPENSATION DECLARATION �
I herehy affirm that I have o�a�„f;�a�e o,�a�e�„o 58�, qpp��CAT10N FOR BUILDING PERMIT
insure,w o certificote of Worken'Compensation Inaurance,
or a certified mpy rhereof(Sec.3800,La6.C.) COUNTY OF LOS AN6ELE5 BUILDING AND SAFETY
PolicyNo. Company
� Cert�fied copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �• �
� Certifiad copy is filed with ihe counfy 6uilding inspec- BUILDING [
tion deporfmanf. AD 55 LOG4LITY .,(J . i
NEAREST
Dote. Applimnf GTY (� Z�p (� CRpu57,
CERTIFICATE OF EXEA�WTION FROM WORKERS' � NO.OF BtDGS. nS5E55pR
COMPENSATION INSLIRANCE SIZE OF LOT taow oro�O7 MAp eOOK p� pp��
(This section need not be completed if the permit is for one �i/.�(_ USE ONE hAAP
TRnCf `T p BLOCK LQT NO. �� -�
hundred dollora(;100)or leu.) _� NO. + '�J �J
� . r TEL SPECIAL
t cenify Hwr in�he performance of rhe work for which�his �WNER w• � ,S rap — OOv corr�iiiOws a
permit is Iswed,i shail nof employ any porsoo in any manner ��� DISTRIR GRq1p iypE FIRE PROCESSED BY Q ���
w as to became subiect to the Wo ers'Compon� ion Laws. P'�RE� � CONST. 20NE U I
7- a-g5 � �
Dafe� a Applicant Q CIiY ZIP STATISTICALGLASSIFICATION • Ap�. �
NOTICE TO APPIICANT: If, aher making thia Cert icrne of ARCHITEC(OR � TEI. � V
Exemption, you should 6ecome Subjecf fo the WOrkeri ENGINEER N�. CUSS NO.�DWF1L.UNITS_ W
Compenwlion prov'uions of the Labor Code,you musf forth- AOORE55 �— SEWER Mqp �
with wmpty with auch provisions w this permit sholi 6e � Z
deemed re�oked. � � � � � CONTRACTOR o.59 -�9 I �� �. YALIDATION —
UCENSED CONTRACTORS DECLARATION uc.�
I her06y uffirm thut I um licenced under provuiom of Chopter 9 AOOREss J �NO. . YALUATION
(commenting with Settion 70W)of Dirisiah 3 of the Business ond �IC. ^/ , O�
Professiona Code,ond my license is in full force and affeo. CITY CtA55 C—�p E ��
SC].FT. NO.OF NO.OF CHECK
License Num6er � Lie.Clpu � b( SIZE S. STORIES FAMILIES ONE
NEW s
co�no«« �NG s D n3!. �1e 'a 3'"�g S oescrsi�riaa oF worsK � F� u r g 1 5 9,5 A
❑I am exe pt under Sec. - ��� C d � ❑ .
AITER FINAI #� ��� • �
8.8P.C.for 1hi3 reoson REFAIR � DATE /L��/�� '
Oate: USE OF FINAL � • •3 b 7 5
ExI571NG etDG. � W����1(� �Fh10L ❑
SiqnOt�re . APRICANT 7E1. BY •��J 4 7 J�c=a
OWNER-BUILDERDEClARA710N PR�M NO. �
I hereby affirm that 1 am exempt from tha Conhactor's license � 0 7,2 2-8 5
Law for ihe following reason(Section 7031.5, Businese ond ADDRE55
Professions Coda): pR
� eua�in�
I, as owner of ihe property, or my employees with ADDRE55
wages us their sple tompensotion,will do the wak pnd
Ihe structure is rwt inte�ded or offered for sale(Section ����TY
7014,8usiness and Professions Code). �y�pyiMG 7E�.
� I,es owner af!he property,am exclusively conMxting � NTRACTOR Np. ,
with licensed wntractors to conatruct tha project(Ser qD02E5S
tion 7044,8uslness and Profesaiona Coda). �
REOUIRED TOTAL SETBAG7C FROM E%IST.
CONSTRUCT�ON LENDING AGENCY �gq�K YARD HWY p�p ��N WIDTH �
1 hereby affirm that there is a tonslruction lending agency for �� FRppR
tha performanca of the work for whicF rhis permit is issued -, p,�,
t5e[.3097.Civ.C.). � � SIDE
- P.l.
Lender's Name � . ` �
$ � P.C.Faa S Permit fae ' �`�
Lender's Address
� I certify tMat l hove read this application and stale that the issuan<e fee 6 r��
� a6ove infprmplion is torretf.I aproa lo comply wifh oll County Investigaflon Fee �
ordinances and State Iaws relating to bullding w�siruction, Top��e �/ �
tl a re6y author' re eaentmives of fhis County to enter �
� u n t ob��e- fi e proparty for inspection purpoaea.
^ `7- aa �V S SEF REVF%E FOR L)(PLANAiOiY tAHGUAGE
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