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HomeMy WebLinkAbout0844A .I LS - WORKERS'COMPENSATION DEQARATION . I hereby affirm ihai I hpve a certificate of consent to self APPLICATION FOR �UILDING PERMIT insuro,or o certificale oF Workers'Compenstion Insur�nce,or a cerefied<opy rhereof(Sec.380D,Lab.C.) COUNTY OF L05 ANGELES BUILDING AND SAFETY' P❑ollcyNa Company _ _ r.,. Certified m "s hereb furnlshed. BUILDING„ �" � y rr� r FOR APPLICANT TO FILL IN nooRess . `.7 � YXC�- 'S"Z t Certified copy is flled wdh the county building inspec BUILDING � "� � � � � ro�dPPa��me�r. ao�Ress,�.�!�� litJ�C1CbJ YK�r �ocnuTv ^�i �-��r,t� j" � �d�ry NEAREST �� / � Date Applicnnt CITY 1 Qr�� t r4���• ZIP �ROSSST, V�/� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS, a55ESSOa � COMPENSATION INSURANCE SIZE OF L(7T NOW ON LOT MAI'BOOK PAGE PARCEt (This section need not be completed if ihe permit is for one IRACi BIOIX LOI NO,��p"'J� U,�E..�Op1E MP,P {�'� __-`� .-�,_ hundred dollars($100)or less.) �' f �� �" TEL. ) (��) SPECIAL � I certify Ihat in the performance af ihe wark for which this OWNEK NQ�l�C%"I��u CONnITIONS (� e mit is issued,I shall not em lo an erson in an manner ' DISTRICT GRUUP 7vPE FIRE PROCESSED BY {,J P-� P Y Y P Y ADURFSS f` . � CONST. � �_ � � so os to bocome subjeci to ihe Workers'Compensation Laws. �`y � ��i,_,��r^sL; � � c� � � CITY Ji�Ka~ ZIP �� � Dale Applicant STATISTICAI�LASSIhICATION c F� APT. CONDO. ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making ihrs Certifi<a1e of N�. �4`��'�4i ;;�qSS NO 4'��C� DWeLL.UNi75_' � eNcwrER Rl�i. ��+�'' Exemption, you should becomc subjeci �o the Workers' »'S Compensation provisions oi the Labor Code,you musi forth- �DDftt55 SEwEIt MAP � wiih comply w�h such provisions or this permit sholl be deemed revokod. ir�- BK PG. VALIUATION CONTI2ACTUR NO. LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm thnt I am licensed�nder provisions of Choprer 9 , AO�R[55 NO. VALUATION (commencing with Sadion 7000)of Division 3 of thc B�slness nnd ' UC Professions Code,and my license is in full force and effect. CiTY CIA55 S� ��`�7 SC�.�T � NO.Oh N(1 OF CHF.CK �i�ense Numher Lic.Class ' SILE ��~Z7 STORIES l FAMILIES ONE n NFW � Contructor Datr. DFSCRIPTION OF WORK ' ��R it� ❑ -t+ AUU � I am exempf from the Ilcenslnp requiremeNs as I um q /(J CL?ti�'r/hlC1E; GI..�C)K K- o �J � licensed archifect or p registered professionol enginr.n,r �� � A�TER � DA E` � R7 n(, , a�rnq '�r, my p�ofess���ai �apa<ny �saa�o� �as, t"KC1i--7 ���'.� �7 � sePniR ❑ � � � Business and Prolesscns Code). USE OF � p{ryq� F.KISTING fiLDG. [7FMUt Lic.or Reg.No. Dqte BY APFLICANT iEL ')'iti� }}k,, OWNER-BUI�DER DECLARATIUN ,PRiNT}+� D� n.r NO. ty l'I7 .--� � I hereby aPPl�m Ihnl I am exempt�rom Ihe Contraclor's License c�- � � � Low for ihe following rensnn (Section 7031.5, Bus�mess and !��kt55 �4����� 9 -'���G���f• Pfaf IonS COde�: PRFSFNT �✓ ��f� t n eunoi:�c M �;t; o • . ,�3 P I, as owncr of thF property, or my ertipinyees with A,�DRE55 �r�'7✓ �� ,r �ayes as iheir sole mmpensa�ion,will do the work�nd �'. Ary� j�e r.,lY+�(�� the structure fs not in?ended or offered ior sale(Section tOCaLiIY . � �r�, 7044,Business and Professlons Codel. MOVWG T<< ' ��'// /�/ # ��'� � I,as owner of the propeny,am ezclusively mntraciing CON7RACIOR NO -�� �i •�'i1�Ri - � with licensed contrauore to censiruct ihe projec>(Seo qpuaetis �[7 Jp +�a���1��'Q tion 7044,8usine.ss and Professions Code). J � aEnu�RFo vnuo r+wv TOTni sFTsna Fkonn exisi. : •a s 7 3,5 0`z-' CONSTRUCTION LENDING P.GENCY SCT 6ACK PROP.LINE WIDiH #f I hereby affirrn ihat there is o mnstrucnon lending agency for Fgp�iT `, ihe perfurrnance of ihe work for which�his permit is issued v t ��7 �� � �� `S�8� (Sec.3097,Gv.C.). SinE "'� �� /'�/�JFI�< Lender's N�me _ . z sz' � I P.c.ree 5 ..?.,...'"'_ve�ma Fee (,y° . Lender's Address_ {� �7 ,. Cl ,Y'/ � � I certify that I have read ihis applicatlon and state thnt the saaonce Fee - Q above informatlon is mrreci.I�c�ree b comply with all County Invozn�mion fee ordinances and State lows relohng l0 6udding consiructlon, Imol Fee and hereby authori�e represenlotives of ihis Coonty to entnr � � �; up ihe aba���-rrie ioned prope insper.lion purposes. �Q�e''� � �r'�� f,� �e� �f SEE REVERSE fOR EXPLANATORY LANGUAGE 5 � � Siqnnt�re o� I�w��or Agent Dn�e 1 �� � � -, x.�:� � �__�� , ,.,�I "' � �'3 „n� { '� ¢ T t 4�, (~ � � �i '�'' ' � ro o �c_ . o a J � n •, � o � � + o � � � c7` m p ��.�:� .{, N p '_T. 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