HomeMy Public PortalAbout8623 GARIBALDI AVE_Building__ WORKERS' COMPENSATION DECLARATION
here,( afflrm'thcrtfica I have r ce' Come of tionconsent to self APPLICATION ._FOR BUILDING _ P.ERMIT
Insure, or a'certificate of Workers' Compensation Insurance, .
or a certified copy thereof (Sec 3800, Lab. C) COUNTY OF LOS ANGELES BUILDING AND SAFETY. ., .
Policy No. Company '
❑ (ertified copy Is hereby furnished. FOR.APPLICANT TO FILL IN BRA loa�
❑ Certified copy Is filed with the county'bulyding Inspec- WILDING
As �6 P6YXI D - —
flon department. -
aW ZIP /-7 7j— LOCALITY
Date Applicant NO. OF NEAREST
CERTIFICATE 0i= EXEAAPTION FROM WORKERS' S17E OF LOT NOW ON LOT J CROSS ST,
COMPEINSATION INSURANCE
hundred
dol need not be completed ff the permlT is.for one TRACT BLOCK ' LOT NO. AMAP SSESSOR
PAGE PARM
hundred dollars{;100)ar less.) ' ' ^� 6Y2� /
OWto J Q z�A/ /-pO NO. ZotE �P '
I certify that In the, performance.of the .work for which this / T r `
permit Is Issued, I shall not employ any.per}on in.any.manner ADDRESS ��oZ 3 W �' cOrmmoNs �+
so as to become subject to the Workefi Compensation taws. -7 Q
J CIN {/ ( ZIP, p 7 7S U
Date l Applicant ARCHITECT OR TEL
.
NOTICE TO APPLICANT: If, after.�aklnq .this CectiHcate of - ENGINffICT GROUP TYPE RE BY QR _ NO. J �. . E
Exemption, you should become.,subject to•the ,Worker' j}�
Compgnsatlon provlsipru of-the Lbior,Code, you muni forth ADDRESS
with-"ampiy with such provisions:.or.this permit shall be TEL STATISTKAL CLASSIF}CATION APT. CONDO. '
deempd r9voked. .- _ CONTRACTOR Q�'� NO. T
LICENSED COtNTI ACTORS.beq,�RATION LIC CLASS NO. UNITS-
I hereby affirm that I am Ilcen;ed uncl"ovlslons of Chapter 9 ._. ADDRESS �' SEWER AMP
(commencing with Section 7000)of-Division 3 of the Buslneu UC
and Professions Code,and.myJLicenyd }Lrl:full forcenndaffect. C BK PG. VALID71TFON
ti�;• SQ. FT." NO. OF NO. OF CHECK'
License Number ;ilc Class _ SIZE STORIES FANULIES ONE
. . . . �-,.- . , t� VALUATIO.N t
Contractor i3afe DESCRIPTION OF WORK f NEW L l
❑I am exempt under.5et 0Q - 17 ADD ❑ ; D
El
B.BP.C. for this reason
F� REPAIR ❑ ;'
Date. USE
Q ~ N DFJNOL F7DOSTIN ' BLDG. /�/i(I L�1
Signature „ APPLICANT TEL
OER-DUILDER DECLARATION I NO. HNAL
WN
I hetpby.afHratthaf I am exempt-from the Contractors License DAT! y
Law fon the following reason (Sectlor 7031.$, Business and sDDRE55 FINAL' `f` f 7 63
Professions Code): _ BY - ITEM I
I, as gwner of the property, or my employees with BUILDING
t Cl Y
ADDS 1
wages as thelr,sole compensation,will do.the work and - ! i ��T( 93. 63
the structure Is not Intended or'offered for sale(Section LOCALITY CHECK �
7044, Business and Profespooliohs Code.) N�. TEL. _ _ �7C�rti
❑ I, as owner of the o y q
CONTRACTOR NO. f C ��•�'
property, am exclusive) contract-Ing
with Ilcensed contractors to construct the project (Set- ADDRESS •4'-�
tion 7044, Business and Profesnlons Code.)
CONS`f17UCTION LENDING AGENCY YARD +WY -TOTAL WO `
I hereby affirm that there Is a construction lending agency for l� tin)
the perfornldnce of the work for which.this permit Is Issued P.C` 9622 1
(sec. 3097, ay. C.). si DE r11 f:►,l`
P.L
Lenders Name Q
17
P.0 FM Permlt FM O LD Ref. •
Lenders Addrew
0 1 certify that I have reod this application and state that the Issuance LDMA P/C tF
above Information Is correct. hoarse to comply with all County IhvestlQatlon Fee. /
ordinances and Mate laws relating to building construction, 1 Total Fee 6 LDMA Per.,a.
s and hereby adthorize representatives of this County to enter
u7he abovo- entl ed property for Inspection purposes.
hSU RFVUM POR 004A ATORY LAMOUA a
Sigrwture of Appllca or Agent Date