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HomeMy WebLinkAbout0060A 2927A (6) , WORKERS'COMPENSATION DECLARATION � � I hereby affirm that 1 have a certificate ot consen��o self � App��CAT10N FOR BUILDING PERMIT insure,o�a certificate of Workers'Compensafion Insurance, or a wr'�'�fviedd copy�hereot�Sec.3800,lab.C.� . COUNTY OF LOS ANGELES BUILDING AND SAFETY Volicyl�'� ���Company�vOLN.IOrIAJ/}7/Bua,,, � Certi4ied copy is hereby Pum�shed. FOR APPLICANT TO FILL IN BUILDING /► � � Certified copy is filed with ihe nly building inspeo BWl01NG ADDRE55 `� �/ �(q��r p� � tion deportmanT. A�DRE55 �/ �pie � ` qpPlica - CITY ZIP LOCALI7V !'jQI�/ ER Ifl ATE OF EXEMPTION FROM WORKERS NO.OF BlDGS. IVEAREST COMPENSATION INSURANCE 512E OF lOT Npyy pry 1p7 � �gp�,5 gT (This seciion need n01 6e compleled if 1he permit� or one TRACT BLOCK LOT NO. 8� ��R hundred dallors(E100)or less.) MAV BOOK PAGE 7ARCE� OWNER q USE ZONE tiV+� �. I certify that in the parformance of tha work for which this �� � ` �� r10. �(� � permit is ia5ued,1 sholl not emploY any person in ony manner R •v y/v�lf1 SPECIAt so as fo become fubjecf to�he Worken'Compensaliort Laws. ADDRE55 r�� '[rl CONDinONS � Dote Appliton! CITY r ZIP ' J �, 9TICE TO APPLICANL• If, ofler mnking this Certificote of ARCHITER � TEL. pI57RIC7 GROU7 tYae FlRE WtOCE55ED BY O � .em lio�, � ENGINEER P NO. p you ahould become su6'ecl to the Workers' CO 20ni F- Compensation prorisians of tlw tabor Code,you must fonh- qpDRE55 2� � �Q n � � W with comply with a�ch provisions or this permii shall be �x deamed revoked. . � L i TEL. STATISTICAL CIASSIfiCAT1�N arr. c oo. tn CONTRACTOR ('f}M�Wa 7}�. NO.U,�"J6� '?yI Z UCENSED CONTRACTORS DECLARATION p C' �� 9 ���, CtASS NO. �WELL.unui5 I hereby offirm tFql 4 om licenaed under provisions nf Chepter9 ADDRE55 U Z�Qpyrl,Q,•�ae7.��! Np,�*3�� (commencing with Satl�on 700p)of Division 3 of ihe Business and ��� � SEWER nAAv Wofeuions Coda,and my license is in iu11 force and effect. Ciiv A.iQyl�- CLA55 b eK. r�. vw�wnnoa SCi.FT.t; NO.OF 9 NO.OF CHECK LlcensB Nvmber �� Llc.Class� 5¢E 75S 57021E5 [� FAMIlIES ONE ._ ..... .,.-'--' .. ..._ � . . - AiUA - . . . ... ... .... . . .....- --.__ . � �)/.. . ..- --- ------ . . COMrottor ��9iM�Wt'�aIL��Dole �0 '�U DESCRIVTIONOFWORK NEW � . .. . _- '.�"�_7n� ❑I am exemp�under Sec. '°DD � � z 0 Q b.Q A AtTER B.BP.C.4or this repson REPAIR � ---f- - - - �• • • �2 3 Dole: %5$TNG BLDG. 1 2. °EM1Aa I •2 0 5 2 8 Signoture ��PRIMr (�' NO.I� '7 FII'!Al F = OWNER-BUILDER DECLARATION � r pq� ��'�C� ••Z(i...`z C��Z> Iherebyaffirmfhallome:CR+qifromtbeCantrocior'sLiwnse qDDRE55 � . ) ��69l.-/�C«il )�.f Low for the following reaion(Set�ion 703I.5, Business and � . ..� fINAI � Q 7,2 2—��C Roffssiorts Coda): gy � � BUIt�ING 1, as owner of�ha properly, or my employeea with ADDRESS wages as their wle campensat�on,will do the work and � the ahucture is not�ntended w offe�ed for aele(Seetion ���ITY 7044,Business and Protestions Coda). MOWNG . ift, � 1,az owner of the properfy,om exdusivaly Conhacting ��RACTOR NO. �, wirh licansad conrmcton to consiruct ihe projact(Sec- !I tian 7044,BusinBsS and Profeesions Code). ADDRE55 �^ UIRED TOTAL SEiBACK L S�Z�7 A. CONSTRUCTION IENDING AGENCY SET BACK YAND HWY pRpp,��NE Wi�TH I hereby affirm tha�ihere is a construction lending agency for FRONT �:�� • • • � the parfwmance af�ho work for which this permif is issued 7.t. �s«.3om,c�.e.)_ sioe I •2 5 2 G C v.�. Lender's Nome � .����-;J� $ •a� LDMA Ref.Y £ lendei b Add�ess P.C.Fea S Permii Fse � i .�.C 7_:��, y� I certify thal 1 have read thia application and atate that the Issuance Fee �•� LpMq p/C N ° obova i�fwmo�ion is correcr.I agree to comply with all Counry Inveelipution Fee w/�.� 8 ordinancea and State lows relat{ng to b�ilding construction, Torol Fee ��"J �(� LpMq perm.M and F�ereby ou�horize repreaentat{ves of�his Co�nty to entar � upon Ihe�agb,o�ve�-m�en ionAd p�operty for inapec�ion p��posea. � �f.�-+!'I V�`.�'�l� J� sai aEVc�roR ExruN�rom uucu�cE Sipno�4J�of Appliwm ar Ag�ni �pde r-- N i-- � C„C� S _ • 01 c� ^ v ��i ^ ,'', .. � ..p Q .,.; �. ^ G µ�:., � J� � v r `O . c �.` ::, q K��"' ' c.. � y :-.a .: „�. .,-,M y,+ X �f w`-C `.;;, 3 6 o e:�s �„G,�z c C p a Y W= . U . `p� �-��� z• v.�M n� d� ;�..� G y �� � c. �- � � C:; .�s „a8 a . -�o y � F " �:z.�,:�� :�+ 0 3,n-�y s � � � � a� a� � �.i = . . 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