HomeMy Public PortalAbout9552BISBY ST_Building (3) WORKERS'COAAPENSATION DECLARAT}ON ~
I hereby affirm car that I haW a certificate of consent.r self
, APPLICATION FOR BUILDING- PERMIT
Insure, or a ceritftcate of Worker' C�ompensatlon Insuranu,
or a certified copy thereof(Sec. 3800, Lab. C.
Fvwd COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polley �� Company 6UILDING
Ce-rflfied copy Is hereby#umlahed. FOR APPLICANT TO FILL IN ADDRESS
CerOed copy Is filed with the tounty building Inspec- BUILDING S
�ttion'department. ADDRESS
Dat4'7 �! ' J�.Appllcdn crry L J LP LOCALITY
(3 RTIFICATE OF IDG
MIPTION FROM WORt_RS' NO. OF 9a DGS. NEAREST
INSURANCE SIZE OF LOT NOW ST.
(This sectlon neid hot be completed if the permit is for one ASSESSOR
hundred dolltpn($100)or less-) TRACT �� �� MAP.BOA PAGE P
I urYtiy =;T.
hat In the nce pf;the work for whlah thisOWW TE t o. USE zor� MAP
NO r Z }}.
permit Is Issued;I s II not imRloy arty.�igrwn Inany manner ADDRESS ' p.
so as to bscomi su6lect to this Workers Zompensat[on Laws.. mom
CrTY / L ZIP
Date Applicant ` .
NOTICETO • ff, after Making this Cwttficate of ARoiaca OR NO.
Dt$TRIC•T ¢R" TYPE RRE BY O
Exeption, you should become subject to the Workers' �j OOtIST• ZC51E
m 8 .
Compensation provisions of the Labor Code, you must forth- A6DRESS S Up lJ�
dwith eemed ply with
. such provisions or this permit shall be Akuh-, Tg i ggs O// STATISTICAL FICATION APT. CbPDO. Z
L}CENSEID CONTRACTORS DECLARAT}ON LtC C ASS NO. DWELL UNITS - ' •-•
ZEUarpd
fit,I am Ik nW under provltlolls of Chapter.9 ADDRESS IL1�1 S NO. 3
Sicttgn 7000)of Dfvhlon 3of the Buslniss and UC W��my 1lcerse U In full force and effedt. CITY CJ=A,SS '3 6K VALDATKM
License NuTla&r- � 2r L1c.,C) `-' -O�
Y DIESCRIPTION OF W(OMo� o VALUATION
Controct7AeIM-a 4lwk Date
61."
I-am exempt under Sec. .S 6�I�✓�4 AMDD ,
ALTER
IL
B.BP:C'for this reason W tiCw✓ 9L 7 W 1464&ALR $
Datb! USE OF EMSTING BLDG. D51hOl
Signature OWNER-BUILDER DECLARATIOfJ ��T �
TEL MNAL
OWNER-BUILDERf� � �m-� ����/� DAT1
.l hereby affirm that I am exempt from the Contractors License ADD�� �c 1J1lJt'F.S A �►
Low for the fol jgwing-reason (Section 7031.5, Business and !7
P1 of Code):
NG
I, as owner of the or m 'employees with �A IDDRESSS 9
PfOP•rtY, Y P oY�
wpgas as their sole compensatlon,will do the work and
the structure Is not Intended or offered for sale(Section CCCALfTY ' I�
70",'Buslnew and Professions Code MOVRJG TEL �`y Qdtl
I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed cgntrocton to construct the project (Sec- ADDRESf12
C tion 7041, Business and Professions Cod}} 9.a
CONSTRVCTION LENDING AGENCY YAW I-WY PROP. UNE 0 ,1291-88
1 hereby affirm that them Is a construction lending ogeri y for PRONT
the performance of the work for which this permit is issued
(Sec. 3047, Civ. C_} SIDE
•P.L
Lenders Name
LDAM Ref. f
C Lenders Acidre" P.C- FM='
Pon it dee
I certtfy that I haw rood this application and hate that the Wouance Fee - 15 LDMA P/AC*-
g above Informatbn I1 correct. I agree to comply with all County Investigation Fee
ordlna $late laws relating to bullding construction, _ Total Fee s LDMA Per, b ;
a a orize totives of this County to enter
a n nt property for Inspectio�n�purposes-
$� f111111111 QW POR URUWATORY LANOUAGN
ale nature of Applkont or Agent a Dais