HomeMy Public PortalAbout9552BISBY ST_Building (6) WORKERS' COMPENSATION DECLARATION
I.hereby q ce that I have r cer;Comp of consent .elf APPLICATION FOR B U lL D N G - PERMIT
�IKsure, or a certJiicate of Workers' CornpensaTlon Insurance,
or a certtffed copy thereof (Sew- 3800, Lab. G.) COUNTY OF LOS ANGELES, BUILDING AND"SAFETY
Policy No. Company BUILDING
❑ Certifled copy Is hereby fu"mished. .FOR APPLICANT TO FA IN Amoss
❑ Certified copy Is filet(with.the county building Irupec- �R, S C'
tion depar#ment.. -� .(
Date Applicant QTY ZIP/.
9-06
/ LpGgLm
CERTIFICATE OF D MPTFON.FROM WORKERS' S LOT TJOW ON LOT v¢ -<_ �T
44 S`T-
COMPENSATION I NSU RANG CRO55
ASSESSOR
(This section rived•hoT be completed if the pettnft Is for on• TRACT BLOCK LOT - MAP BOOK �- PAGE ' P
hundred dollars{$100) or less) OWNER S' TEL !Q Sd ZONE MAP
I certify,that to the performance of the'work for which this
permit Is Issued, I.shall noSPECLAL
t employ anyperson In arTy-manner ADDRESS �- !S CO MONS
.so as to become subject to the Wockeri Compensatlbn.l,aws. Q
CITY X Z1P 7 7r a U
Date Appllcant. ARCHITECT oRf TELtY
NOTICE TO APPLICANT: If, after,making this rdlficate of ENGIN. NO D CT GROUP TYPE PROCESS.BYExemption, you should become subjectto the'' Workers 3 �� J:JE
'
Compensation provisions of the Labor;Code, you must forth- ADDRE§S J l/
with.comply with such provisions or this permit shall be- TEL STATISTICAL CLASS]PrCAWN APL I CONDO. N
deemed revoked.. CONTRACTOR NO. Z_
LICENSED CONTx2ACTORS DECLMATION UCCLASS No. DWELL UNITS �
I hereby affirm that I am Licensed under provWon}of Chapter 9.. . ADDRESS NO. MAP
(commencing with LIC.( g Section 7000)of Division 3 of the�uslness
and Profeplons.Code,anc(my license Is In full force and effect.. CITY CLASS -"PG. VALIDATION
SQ.FT. Na. of - NO. C* CHECK
Ucense Number ' I Ic_ Clas6' SIZE STOF ES FAMILIES - ONE
T1CMl
= a+`Np/�
Contractor r pats PWORK NEW O(J•
❑I am exempt under Sec- ADD ►
. - TER -.
B_BP.C. for this rf►ayon �' r REPAIR ❑ $
OF
fie' bQSTING BLDG. DEMOL ❑
SlgnatuFeJ APPLICANT TEL(PRINT
. 9
FWAL
OWN.ER-8UILDER DEOARATICNJ DATE
I hereby affirm that I aryl exempt from.the Contractors License _
Law for the following hKmon {S¢ctlon 7031:5, Business and 'ARES FIF(AL
Professlons Code): PRESEW M14,
❑ I, as owner of ffi r BUILDING ACCT.i
4 Fi operfy, or my emplgyees with ADD
wagesas thelr sole compensation,will do the wgricandLOCALITY ' -3307 .
the structure Is not Intended or offered for-sale(Section
7044, Business and Professloni Code.) MOVING TEL 1 ITEMS
I, as owner of the property, aro exclusively--oontractICONTRACTOR NO'
with Licensed coniroctbrs to,consiTnct the proles (Ssc- •
tion 70144, Busine».and Professions Code.) ADS t i ]�?.�},
CONSTRUCTION 1�JbING ACNCY YARD HWY FROM- ' _ . .
I hereby affirTr�.that there-Is a construction lending agency for FRONT
this performance,of tho work.for which this perm M'Is Istyed P.L
(So,X097, Cly. C.). SIDE• ����ii i r i
P.L. - - _ L9.AJLnlLrLt
- Lender's Name
C P'G_FM Puma Fee r LDMARaf. f X52 1 AM .7:5?
Lenders Address - -
o I certify that I,have read this appllcatlon and state that the Isuranoe Fee LDMA,•PiC#
above Information Is correct. I agree to comply Wlth all County Ihyes rlgatIon.Fee. f�..�
ordinances and State laws relating to building construction, 3
vction, Total Fee � �! CDMA Psrm. #
and hereby authorize eprosentatives.of his County to enter
;anthie above �oonred
o f r Ion purposes.
fU ItFVEW PM DQ'LAIiATORY LA##UAW.
rwtu or Aunt - Date
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