HomeMy Public PortalAbout9552BISBY ST_Building (4) WORKERS'COMPENSATION DECLARATION ;
I hereby offlrm tisat I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT .
lniure, df a certificate of Workers' Compensation InsurdnC6,
or a cbrtff��,,�dd r Lab.C.J
W�` J� �" L ptiJ COUNTY OF LOS ANGELES BUILDING AND SAF
PbIIcy No. Company
., Certified copy Is.hereby furnished, - FOR APPLICANT TO FILL IN ADDRESS ADDRESS
Certified copy fs filed with the cou ulldl Inspec- b111LDING
tlon depatr�fiie}fiy,T��i ADDRESS 6�
Date ���0 :-'�Tppll Fit" TC-1 1 � ZIP' DD LOG.LITY T
CERTID ATE OF FROM - NO.OF"9LDG6
NEAREST
"
COMPENSATI INSURANCE SIZE OF LOT. NOW LLN
ST.
(This section'need not bq'.com-le ted jf th+ permit Is fo,,'One
hundred dollars ($1,00)or less. .• M,qp BOb1C PAR{ L
TEL USE
•1 certify that. the,Perfbrmance of the wark•fcr whim this • Olhrt6t NO,' NO.
penult Is issued, I&hal l not employ any Person Irr any manrer' ADDRESS �' � SPEC]A1
so aE to become sub(ed to the Workers Comperaatian Lata. T r C� CONDfTI(yftS 8
Doti I Icant
CITY. J >v wt Q l • }�.. ZAP ( 1
T OR TEL DMW. LFP TYPE 6Y
NOTICE'TO APPLICANT: If, after'making this Certificate.of W.
Exemption, you should become tabled to the Workers' ENGtObt�sr. "IOrf
Compensatlon lxovlslons of the Labor Code, you-must forth- ADI
with comply with.-such prpvlslons ar.this_permit shall be - - S�`� t Ti 7 07
AT15T1CAL CLASSI IyPT �'
deemed revoked, ODNTRACT6R
UCENSED COr�JTRACTORS DE0ARATION )) LK- bAsa NO. DMIL UNrrS
'.—]
I hereby affirm that I am IIceraed under prpyblgns of ChopW 9 A�DRf55 IO 0 '/e�/7� NO.
(commendng W"Sectlan 7000)of Division 3 of the Business and
UC- StWER MAP
ProfesslPns Codd, and niy license Is jn MI fortd and effed:' CITY tJQ CLASS C� PG VALIDATION
{� C / SfC� W.S� ONE
CHECK
License NJmb'gr V I Uc.
QQ VALUATION. .
•ContraCtorl7fl-�� Or✓�!Ni paid DESO�IPTION OF
WOM NEW
ADD =
I am exempt uhder-Sec' - "r "'� `�^� � ,
., r ALT$?,
B-, P.•C, for thb rodson T 0— r AIR = -
.. Date: USE OF
tJG BrS3o.
Signature TEL RNAL ��
OWNER-BUILDER DECLARATION ,PRI No. DA 1 . �,0 0 L 2 A
I hereby affirm thqt I-am exempt from the Contcocto's Uperise
Law for the following reW. n (Section 7031.3,Business and ADDIZIM
Prbfeesiotti Cdde)!. �o a e to • 1
BUILDING
F1 I� as owner of the phop•rty, or Ivy }mproyes with ADDRESS = p,;° 6 8,6-3
tad cri therr sole..compensatlon,wil l.do the work and 6 b 3
tie structifj'e Is not Intended or offered for sale(Section o i •
7044, Business and Professions Code' . - MOVING - TEL
f,as owner of the property, am exclusively tontroctlng NO. f _ 6 2 8 8 8
wffh'Ilcetlsed contractor to construct the prolect jSsc- -
ADDRESS
Hon 7W4,.Bus7neis and Professions Code).. }
CCM1$TRUCTION LENDING AGENCY YARD it1NY yyI
r hereby gffJrm that there is a construction lendlrlp'ogencyfdr
FRONT
the perforrr)arce of the work.for which this pbrThlt is Issued L
(Sec. 30'97, Civ. C. SIDE
} P:L
[enders Nome
$ IDMA Ref. It .
Lenders Address P.C. r« n Fee
1.4erttfy that.I flaw riod this apoltat(on and state that the Insuanu Fee TDMA P/C tf .
above IrTFon,bdtton is correct. I agree to coTply with all County• Investi�atlon Fee
"ordinances and $tate krw4 refating to building construCtlon, . .
and a repr twives of this County to enter Total Fee LDMA perm, /
U e Ho ion
o !iVlf✓t KM EMANATM LA1iOlJAW
Si of ktmm or Agent pure