HomeMy Public PortalAbout9548BISBY ST_Building (8) WORKERS'COMPENSATION DECLARATION -
sure, affirm t� " ° ° certificate of
tion insurance,r ce, APPLICATION FOR BUILDING PERMIT
Insure, ora urtlflcate of Worker'Compensation Insurance, I."
` or a certiflcopy th (Sea. 3800, C
Pollcyl mpany � COUNTY OF LOS ANGELES BUILDING.AND SAFETY
Certified copy Is hereby famished. DING
FOR APPLICANT TO FILL IN ADDRESS
Certtfied copy is ftled.with the county building Inspec- P, BUt1Dl
tion department. ADDF2E55 LOCALITY
�l� // NEAREST L/
Date Appllcgnt C7T1' /�'L /�` LP / CRO55 ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS- ASSESSOR OF
COMPENSATION INSURANCE SIZE OF LOT NOW ON MAP BOOK PAGE PARCH
(This section need not be com leted if the permit Is for one US> ZONE o�
hundred dollars (;100)or less. TRACT MOCY LOT , �'
r SPEC]AL }
I certtfy that In the"performance of the.work for which this ONRER CONDITIONS D-
permit Is Issued, I shall not employ any person In,any manner C DISTR}CT OROUP TYPE Z PROCCSS®BY
so as to become subject to the Work" Compensation Laws. J Ta(/ 3 �
Date AppNcant ARa ITIECT OR DDRESS
CTTY LP STATI5TK:41 TtOiJ DO. 0
NOTICE TO APPLICANT: If, after making this Car tfflcate of
Exemption, you should become subject to the Workers rlt� �' C1fS5 NO. UN
Compensatlon provisions of the Labor Code, you-m6gt forth- ADDRESS SEWER MAP
with comply with such provisions or this permit shall be pL PG �� t
deemed revoked. t/ AOR44A4 V 4 VALIDATION
X LICENSED CONTRACTORS DECLARATION h
V I hereby affirm that I am licensed under provisions of Chapter 9 V VALUATIQN
(commencing with Section 7000)of DlvWon 3 of the Business and UG ss _
✓ /J D
Professions Code, and my license Is In full force and effect./
License Num 2dc) Llc Cl �'1` I S0. FT. NO.OF / NO. Of C1IEO( ,
SIZE STORES FAMILIES oNE
�
Contra � I l DESCRIPTION OF WORK NEW ❑ s
f, ADD
I am exempt under Ser- I-o ,D 9W
ALTER FINAL
B.BP.C. for this reason A Q DATE
.�J/ / REPAIR
Date: f LT1ING BLDG.wNT)ZX/�r W.e i L{�/ �y XAa ❑ E
Signature'
L�✓�Y /T ZLJ/L_ �V? : r c Q F
OWNER-BUILDER DECLARATION . Z -
I hereby affirm that I am exempt from the Contractor's Ucerse
Law for the following reason (Section 7031.5, Business and406=/
/
Professions Code): - �[/ 1
I, as owner of the o BUILDING
�r perty, or my employees with ADDRESS
wages as their solecompensation,will do the work and
the structure Is not Intended or offered for sale(Section LQCAUTY
7044, Business and Professions Code r57SE?'"'
TEL
I, as owner of the property, am exclwlvely contracting
with licensed contractors to construct the project (Sec.
tion 7044, Business and Professions Code CONSTRUCTION LENDING AGENCY YARD HWY TOTAL FROM DDUDSTT. C,
I hereby affirm that thele Is a construction lending o�ency for the performance of the work for which this permitIsIssued(Sec. 3097, Cly. C.). SbELenders Name13Lenders Address Permtt Fes J
I certify that I have read this apply:r Ion and state that the Issuance Fee /Q - J—d `1 e
above Infornwtton is correct. j agree tocomply with.all County I Fee
ordinances and State laws relating to=g construction, Total Fee
and hereby authorize 4,ntativaGethis County to enter
upon e a enNon Minspection p — -
�/ SM KW EUMAllATO[Y LANGUAW
if -
Signatun Appl;a t Date