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HomeMy WebLinkAbout0648A WORKERS'COMPENSATION DECLARATION � j I hereby af(irm that 1 have a�e�„f;�o,�of consent ro,e�f APPLICATION FOR BUILDING PERMIT i ins�re,or a certificate of Workers'Compensation Insumnce, or o cerNfied<opy the�eof(Sec.3800,ta6.C.) COUN4Y OF LOS ANGELES BUILDING AND SAFETY Policy No. Compony BUILDING /7��p , _p„ , � � ce.+ticed coPy;s hereby 1v���ahed. fOR APPUCANT TO FILL IN ADDRESS ������' � � Certified copy is filed wieA�he county building inspeo Bl11LDING �/ lion deporfinent. A��� " � t DOtb A�1{iCOM CRY ZIP LOCALfTY � CERfIFICATE OF E%EMPTION fROM WORKERS' NO.OF BtDGS. NEAREST COMPENSATtON INSURANCE SIZE OF lOT NOW ON l0T CROSS ST� �ihii aettion nrod not 66 completed if the permit Is for one - �S'� - � hundred dailars(i1QU)or�eis.) T��T BLOCK LOitJO. MAP BOOK PAGE PARCEI USE ZIXJE � I certify lhot in the performance af the work for which this OwNER b NO. permit is issued,1 shalf not employ ony person in any monnor ���A� d � w as to become subject to rha Wor4era'COMp6nqtion IAws. A�RE� � CONDITIONS CITY ZIP �Z �. DatO App�kont ARCHITER OR `` 1 TE�� � OISTRICT GROUP ttPE FIRE PROCESSED BY O NOfICE TO AP%ICANT: If, after making this Canifitate of ENGiNFER Ih'N �� / � CON��� ZONE U Examplion, you ahould 6rcome subject to Ihe Workers' �� Cpmpertsatio�provisia�a of lhe lAbor.Code,you muat furth' ADDRESS v J�� � with comply wilh wch provisions O� lhis prrmit chal! be TEL STATiST1Ut CL4551FKATIpN APT. . (n desmed revok6d. � LICENSED CONTRACTORS�ECLARATION �NT��� ,y�.p,/ ? �u�. DWEtt.UNITS z 1 haraby offirm thol l om litensed�nder provisions of Chap�er 9 ADDRESS 0 16N" NB OG7 � ��R�y (wmmencing with Section 7000)of Dirision 3 of ihe Business and uC. Pro}essions Cods,and my licensa ie in full force ond effed. OTr 1 C�-45S BK � VALIDATION 5q.FT. NO.Of NO.OF CFIECK LicenseNumbbr Cic.Class SIZE STORIES FAMILIES OME � wuuanoN �ESCRIP710N OF WORK �W Conlroc�or Dafe qpp � s � �I om exempt�nder Sec. A�.�R � �0 6 4 8 A B.BD.C.fw fhis reown REPAIR f #• • . •�3 ��e: ex sS r•,c BLo�. °E"`O1 I • •L 5 O O SignOture APPIICAM TEt. FfNAL OWNER-BUILDER DECLARASION PitiNi NO. �Tf • • •2 5,i,(;� I hwoby affirm thu�I am exempf from�he Cantracror's License qDDRE55 FINAL law for tha following twaon(Soc�ien 7031.5,Business aod � �����a� Rofeaions Code�: �� -- � � r o �,�,� I,os awner of the property, or my employaes wifh ,o0ORF55 wagos as iheir sole tompensa�ion,wilf do the work ond L��ry � �he t�ruclvre is eol imended or offered for sale(Section 70A4,Businesa arrd Profeaeions Code). /��� �l. � 1.as owner of the p�apeHy,om axclusively contracting COhITRAttOit �. with Ilcensed conhacfo�s to mnslruct Ihe projett(Sec- qDDRE55 i // � /�'L O rion 7044.Business and Professions Code). ,j�yvw vi�•�,� RE(.lU1RE� TOTAL SET � VARU HWY /�`" fONSTRUCTION LENDING AGENCY SEf BACK PROP.IINE WiDili V I hereby affirm that Ihere ia a construction lending a9ency for FRQNi the performcnw of tho wqk�or which�his permil is iswed P.L. (Se[.3097,Civ.C.J. SIDE P.l. �ender's Nome tDMA ReL M $ P.C.Fee S ��•� Psrmit Fm � Lender's Addrass � 1 cerlify�Fw+1 hava read�hia applica�ion and state ihCt the Iswance fee ��P��k above infwmation is conect.1 oyrea 10 comply with all Couny ��reaiiyu�ion Fee 8 ordinonees and State lows relafing to building wnslrudion, Toal Fee IDMA Perm.M � and hereby Ihorize reprasantat' e of thie County to enter � uppn t4 - en io e op 1 for insQection p rpo s. � g�g SEE IIFVfpf!fOR fYW�1NATORY LANGUAG! Signawn oi App kom or Ap�nt � , ,L` 4, t y _ y u ` � N C y v. ., � ' . p �T',�,'. � «~ t� C, �c. � � .r.'~ y V r y ' .�.::.� n,a � 7� .C� � � C u vr•+ r 4 v L LL ` t . F �:� fi�� �.C 3 '� `�'�` ~ �' a w L C., y' O •�.. � � � u L `� 11 ' ` 7 f� ,n i. G�.� �' ' �v: �� C' s u... � t . 1 �.... � �r O-", �,-` �' m xi � i •t .,1'� c, - «.^= �� : :."��.. �yy .e' �N-�Y-"' c,�V� � l�•�,r t„ O F � � f � "' " "�. V, ^ �V w 4 ew � C �..i �, � �t�^, � i. .?� `T ^ :�` F � {y.t> cJ . y :;�3 X � ''� (� . �c a.c'. � .,� n.... s". 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