HomeMy Public PortalAbout5603 SULTANA AVE_Building__ F, - WORKERS COMPENSATION DECLARATIONhereby affirm that I haver cs Come of tion Int to self - APPLICATION FOR BUILDING' PERMIT
insure ora I'm that I of Worker Compensation con Insurance
or a cenlf,ed copy thereof (Sac 3800 Lob C ) /
Policy No 75'IiLY/ Zompony S' U COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is hereby furnished FOR APPLICANT TO FILL IN BUILDING D3
BUIlDIt4G
Candled copy a filed with the county budding mADDRESS 15-17
eP
tion deportment ADDRESS 560 SATA06 AVENUE
Date gin>Applicantr^1 CITY ZIP LOCALITY '
CERTIFICATE OF EXEMPTION FROM WORKERSNO OF BLOCS Z NEAREST
COMPENSATION INSURANCE Slif OF LOT [Cs/C>OD NOW ON W7 CROSS ST
(This section need not be completed If the permit Is for one BLOCK LOT NO MAP PAGE PARCEL
ASSESSOR
hundred dollar ($100)or less )
USE Zc NE
I certify that In the performance of the work for which this OWNER A NO
permit Is Issued I sholl not employ any person In any mannerADDRESS D SPECIAL -
so as to become subject to the Workers'Compensation Laws COFOITIONS
ZIP 8
Date Applicant d
NOTICE TO APPLICANT If after making this Certificate of ARCHITECT � DISTRICT P �T I Z D BY O_
Exemption, you should become subject to the Worker' EER I&b J V
Compensation provisions of the Labor Code, you must forth �pgE� �L� 54� LLLpy����
with comply with such provision or this permit shall be CONTRACTOR /V w TEL
STATISTICAL CLASSIFICATION _ APT CO
deemed revoked Z
LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS
I herby off um that I am licensed under provisions of Chapter 9 ADDRESS 2 NO
(commencing with Section 7000)of Division 3 of the Buenas and M SEWER MAP
Professions Code, and my license is in full force and effect CITY CLASS 410 - BK 11 PG - VALIDATION
i SO FT ZOO NO OF NO OF CHECK
License Number Lic Class Z SIZE STORIES I F LIES ' ONE '
VALUATION
T.Rw
Contractor L✓ � »1�� DESCRIPTION of woaK K ADD , 1
131 am exempt under Sec ALTER
B dP C for this reason REPAIR $
Dote EEx,sT NG am _ RES-110451i DEAIOL
Signature APPLICANT TEL FINAL _
OWNER-BUILDER DECLARATION (PRINTI NO DAT{
I hereby affirm that I am exempt from the Contractor's License i
Law for the following reason (Section 7031 5, Business and ADDRESS FINAL
Professions Code) BY
I nt owner of the y employees ADDRESS
property, or m am to es with ADDRESS
wagesm their sole compensotlon,will do the work and LOCALITY
ise e e 0,1
the structure is not Intended or offered for sole(Section
70", Business and Professions Code) MOVING TEL e e 6 Q 5 0
1 m owner of the property, am exclusively contracting
with licensed contractor to construct the project (Sec- ADDRESSe • • 6 Q 5 Q 5
non 7044, Business and Professions Cods) l) Q 9.0 8 8
CONSTRUCTION LENDING AGENCY YARD HWYTOTAL PROPBACK f RCIVk MST LINE WIDTH
I hereby affirm that there a a construction lending agency for FRONT ,
the performance of the work for which this permit is issued PL t -i
(Sec 3097 Cv C J SIDE
Lender's NameT�N �L AF CAFG 01 A P L
$ ll IDMA Ref 1
e"33a s ALAME MA-L.A.OA 9=3 P C F«3 Permit Po. E/
Lender's Addis
1 certify shot I have rood this application and stale that the Inucnce Fee r� IDMA P/C•
above Information Is correct I agree to comply with all County Investigation Fa -
ordinances and State laws relating to building conitructlon, ,t \�\�� .\L. s •'-r\
Tobi Fw LDMA Perm 1 �. .
and hereby author:,repr tonves of this Count'to enter =�"
upon the abo enhon _pp6perty for inspection purposes
9�» 3n RFVEM FOR EXPLANATORY LAWWAGE
S,giwbre of t or Agent -