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HomeMy WebLinkAbout1029A 1264A (9) � WORKERS'COMPENSATION DECLARATION . . . . . - . ' . . . � �� iere6y affirm that I have a cerlifimte of�a�=e��,o,e�F . . � qpp��CATiON FOR- BUILDING PERMIT -�� �we,a�o cer�ifico�e of Workers'Compenslion Insuronce,or , rertified opxihereof(Sec.3800 ob.C.) COUNTY OF LOS ANGELES BUILDING ANO SAFETY. ��2S��E°/ �11/ j . - dicy o. Compony� � +'� gUILDING �' Certified copy is hereby(urnished. FOR APPLICANT TO FILL IN ADDRE55 2Ci�.7 d�'K�a JCertified copy is Tiled with ihe co�nty buitding inspec- BURDING � �„t��O ip�q�iTY- �LA�M O/�� �J��- . fion depariment. ADDRESS NEAREST ita��Applitant CIiV � bl.'� Zi� CRO555T. CERTIFICATE Of EXEMPTION FROM WORKERS' � . � NO.OF atDGS. a55E550R - �' COMPENSATION INSURANCE SIZE OF LOT NOW ON LO7 MAP BOOK PAGE � PARCEL � �his section need not be corriptered if ihe permit is for one , USE ZONe MnV , �ndred dollars(5100)or I¢55.) TRA�T BLOCK LOT NO. NO. �� 7 3 • � � T L SPECIA� a ceitify Ihal in the performance af Ihe work�or which this, _ OwNER ' -��1[��G F � ti� � CON�ITIONS Q , ermif is-issued,1 sho�l not em lo an erson in an manne� ��� t� f;r DiSTRiCT GROUP TYPE FIRE PROCESSED BY (J . P Y Y P Y AODRE55 J CONST. ZONE � ��as to betome subject l0 1he Workers'Compensation Lows. _, � (D" � o ale APPlicanf '� ARCHITECT OR�•� ZIO TEL. STATISiICAI CLASSIFI TION APT. CONDO. V IOTICE TO APPLICANT: If, after making ihis�Certiiicale of � W ENGINEER NO. CLA55 NO.�DWEII.UNITS C. xemption, you shauld become subjecl �o �he Workers' v� :ompensation provisions of fhe Labor Code,you mvsl forth- ADDRE55 �� � SEWER MAP Z ith tomply with such provisions or�Ihis permit sholl be TE� - . leemed ievoked. . -. coNTRACTort r�� NO. bZ. eK• �• VALIDATION � � LICENSEO CONTRACTORS DECIARATION -` uG` pr� . � he�eby affirm that I om licensed under provisions ot Chapler 9. . AD�RE55 � . �.. ��(eN NO. ` -t �. VALUATION �1 0 2�.9 A � { commencing wirh Sec�ion 7000�of Division 3 of the Business ond �i�, ]�-7 �.+,p0 'rofessions Code,and my litense is in full force ond effect. GITV �7�� O� CLA55 �� s F L � � ' , ^��;� � „� SO.FT. NO.OF NO.OF CHECK #'��•'� �Z`3 .IcenseNumber �� Lie.Class�-��' � 512E STORIES FAMILIES ONE �S .. .�I •-•-� 8�10 d� e!r �� �/� �� DESCRIMION OF WORK S% NEW :ontractor M({.�/����GV Dote 1.L�SL� . ADD ~ ��.� a�'�_ ] I am exempf from the licensing requiremenis as I om a 7'�X y� ❑ p / � U licensed archi�etl or o registered proiessional engineer..... . - y� A�TFR a DA EL O/'�J/iPa �2'� 5,�a�. , . acting in my professionol copaciry (Seclion 7051, � ��'���w� 1 aEaniR � Business ond Proiessions Code). USE OF � FINA��/� /--� � ' . , - � EXISTING BIDG. DEMOI e }� �_, . ' Lic.orReg.No. . . . . Daie A7PLICANT tEt. �/1 -- �OWNER-BUILDER DECLARATION�� - ���-�' � fPRiNT� - ` NO. - ,U I hereby affirm Ihat I am exemp�from the CoMractor's License - . � - � law.for the following reoson(Section 703I.5,_Business and ADDRESS � ProfessionsCode): . ; �� , Fii�'N� � � ' . ❑.. BUILDING - . . ' ' ' I, as owner of ihe property, or my employees with ADDRESS aaes os�heir sole compPnc��ion,will do Ihe wcrk and . - ihe structure is not intended or aftered for sole(Seclion - " �aA�iTY . � '7044,Business and Professions Code�. MOVING . TEL. - � � -I,as owner ot Ihe property,om ezdusively conhaclinq � CONTRAC70R � NO. �� � � with licensed mnrractors to consirucl the projed(Sec- qoDaESS � - .- - tion 704d,Bosiness and Professions Code). - . �� � REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SEl BACK YARD HWY PROP,IINE WI�TH ' I hereby affirm thol�here is o mnstroction lending agency for- FgONT � � � the performance of the work for which Ihis permit is issued v.L � � � �� 2�l 4 p � � .(Sea 3097,Civ.C.�. . , _ . . . . . SioE . . . . . . P.L Lender'sNome � . .. - � ��• • • • •;� P.C.Fee 5 Permi�Fee d � ' �� � 3�.5� Lender's Address �y �� , I certify tha�I have reod ihis opplication and s�ate�har ihe � issuo�re Fee J � • above informaiion is mrrect.I agree to comply with'all County _ � �nveaYgo�ion Fee � � r � � .- �� . ordinontes and Slate laws reloting ro building conshuction, iotol Fee J � an �he�e y o orize prese �es his Counly lo enter • • •3 1,5 0� �ap n I 6C e meNi ed pr pe ry r� specli6n purposes. . , , . - � i-z���'� ,' • SEE REVERSE FOR FXPtANATORY LANCVAGE Signalure of Appliconl or Agem Dote , , ' . � - ' � � �� ' - .. iz -� 00 *' (!i T q m � D O �� � ,. � , T r p p.l o� .�� �' O {py � o -, � ' r r" m � N 0 �� 7r �7: 7 ^. .�v� �O j� O S n- . ! m T tl S p o 7 o Q � o �:J. :'-%o . n� v .c7 �p ,j � Oo. . �O 5 7 tT�. rp �� : aJ n.�. O � =. � - �' � �� �N .i Do ,� q 0. F; ,0 1 �... �� Q� 0 3 o n a � . Cj 'o � =Z ._,x �K �� a� 4�� o C� n. o� ° °' � 3 ro p a � T S�C m O �G '♦� N � � y 3��. � 19' y M . 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