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HomeMy WebLinkAbout0059A 2930A WORKERS'COMPENSATION DECLARATION � � ' I hereby affirm ihat 1 hove o cenifica�e oi consen��o self APPLICATION FO�t BUILDING PERMIT inaura,or a certificote of Workers'Compensation Insuronce, t or a cert�t�ed copy theraof(Sec.3eoo,�ab.C.) , CpUNTY Of L05 ANGELES BUIIDING AND SAFESY c(7-�.h,L�01� PolityNtic�-�r�Cort+pa^YSvP�z►� N�+e�� BWIDING .�r n � Certified copy is hereby iumiehed. FOR APPLICANT TO FILL IN ^ ADDRE55 �� � V v�l CN Nh• QCerlified coBY�s filed with the county b�ilding inspec- BUItDiNG /� rr � tfon deparfinenf. ADDRF55 � U � Dala 1��� Applita�t �k��^^"'l��i CISV ZlP tOC4lITY �Qn..^�+`� �� CERTIFICATE OF EXEMP710N GROM WORKERS' ������ NEAREST COMPENSATfpN tµSURANCE SIZE OF lOT NOW ON LO7 CRO55 Si. (This section nead not be completed it the perrt�ie i�ior one A�'�R hundrad doliwa(t100)or less.) TRACT 3� ' BIOCK l0T NO. ¢� AM1AP BOOK PAGE PAR�I owr�R '�_ use zor� � �i I ce�tify that in the performonce of the work for which thia �� l r���f � � SPECIAL O' permit ia i�a�ed,(ahal)not emplay any person in any monnar A�RE� � g �( �� �DITIONS so os to become wbject fo tha Workers'ComFunwtion[awe. V CI7Y g Z�P �' Dote Applimnt ARCFtITECT OR NO. DISiRICT GROUP NVE FIRE PKOCFSSED BY OO � -'�TICE TO APPIICANT: It, oftar making�this Certifimte of INE R � ZONE emption, you ahould become �u6jett to the Workers' ,i ��l W Lompensalion provisiorn uf tho ia6or Cod�,you must fwth- ADDRE55 `� i, ��� �«I� �u �` � � Q-` wilh tomply wilh such provi6ions or fhii pYrmit ehall ba t L STAT75TICAL CUSSIFICAiIOM APT. � � deamsd ravoked. Cpo-iTRpCtoR Yl.�t Wl r7trx�, `L(3(�34"7�f �n� Z IICENSEO CONTRACTORS DECLARATION �,s' �p�,.,�(��;_ - - Ct.455 N0.�LOWELL.UNITS 1 heroltY affirm thot 4 am licensed under provisions of CFwptx 9 ADDRESS i-b �"��'"'�'�"�'�O. �J�7�� gy�A MAi (camme(uing with Senion 7000)of Divicion 3 of the Bualneas ond �, ��- UC. � Profaaions Gode,and my licenaa is in full fores ond effxL Cttv C�u 8K. pG. y�'�dAT� SO.FT.. NO.Of FMh1�5 CONEK Lieense Num6er ����� ltc.Cfass -� � SIZE 1 STORiES � Q YAWATION � � qo DESCRIPTIONOFWORK "E"` 0 s 2G SOD co��,«�o.A ern-nn�W �svh ��. „oo � �I am e:empt under Sec. �� qLTER ��0�'�A 6.8P.C.far this�wson ��'�•lV�''- REPAIR ; #• • • •L 3 on�•: Ex�sT°Nc s�oc. r l.C. °EA''� I • 1 5�8 5 Sipnoturo �R��i � �t. FINAL PRINT NO. L OWNER-BUILDER DECLARATI�N p DATF -7, ���j •• � �3,;�J� I hereby offi�m that I am exempt from the Contractor's Liti�ss ADDREu Z�Gi(} �� �7 0 4��+.f ,f I)•r�..(/ F1NAL Low for the 4ol{awing rcason(Section 7031.5,Businesa ar+d � ./ ��.�2"'�8 Profeu7ona Code)� euitoiriG � � 1, as owner of�ha propsrty, o�my employees with ADDRE55 wpye�Cs their sole tompanwtion,will do Ihe work and ���Ip, � the structure ia�ot intended a o44ered for sale(Secfioa 7044,Businefs and Professions Cods). - MOVMG TEL. � I,as owner of the preperty,em ezciusively contmcting ��TRACTOR �� with(icensed comracton to construct�he project�Sec- qpDRE55 tion 7044.B�siness and Proiessions Code). , REIXJI D YARD MWY TOTA1 TBA K �, CONSTRUCTION LEN�ING AGENCY SET BACK PROY.LINE wIDTH I hereby affirm�hat�here is a construction lending agency for FRONT �2���� � �he performance of the work fa which thie permit is issued P.L. ($eC.3097,Civ.C.). SIDE �•�� a �7 V.L. Lendar's Nome � .� LphW Ref.M � � � C�'"�' W P.C.Fee S l� Pe�mit Fee � � - :� _. Landar's Addross � 1 '� i �' . .' � I certify ihm�have read this application and slate thot the Issuance Fee ���� ��P/�k obove informo�ion i6 corrett.I ag�ea to comply with all County �n.es��gation Fee / ,` ' �,C%—�.R ardinances and Stote fowa relating to 6uilding construction, Total Fee / �•V � �MA Verm.M R ond hereby authorize representatives of�his Counfy to enter upo�the�+a6orrvo-men on Qroperty for Inspectio purpoaee. M1 , I�/;���M���� !� � SEE RFVEYSE FOt EJ(HANATORY IANGUAGf Y Siprw�Lre of ApPIimN or Aqenl te r �. � v� N �.. c� R ' �.�' - � �� v N� � � e t C u u'�`"Z �.. s . O,.- . w.��" ^ � � "1 Q L'. `.�, p +a� O� Qi C .Y a' r. `L�'„�� S V:'/!' '.`^ '�C �3 O 0 y x �y-' � G l/1 .�- " . p^ " � `T,Gy Y .". 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