HomeMy WebLinkAbout10_28_1982 - 2016 PEACEFULL HILLS RD WORKERS'COMPENSATION DECLARATION . �
I hereby ofF��m,ho�� �a�a a�e�;�;�a,a oF�o�,e��,e se�f . APPLICATION FOR BUILDI NG PERNII�
fnsure,or a certifimta of Workers'Compensation Insurance, �
or a tertified copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � ,
PolicyNo. Com ony BUILDING
� Certified co y is hereb furnished. FOR APPLICANT TO FILL IN aooae55 � l
� Certif" d c y is filed wi anty buildiag inspec- BUILDiNG
tion apa ent. ADDRE55 LOGAtItt
I �y NEAREST
Da(e` Applitont � CITY Zia O CROSS 5T.
- C IFI TE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. ASSESSOR
� COMPENSATION INSURANCE SIZE OF LOi NOw ON LO7 MAP BOOK PAGE PARCEL
(This settion need not ba compleled if tha permN is for one USE N MAP
hund�ed dollars(E100)or less.) fRAR BLOCK lOT NO. /A� NO. ��
� - � T l. / / SPECIAI -Y
I certify that in the performance of the work for whfch this OwNER (js G� O. '�� CONDITIONS d
ermil is issued,I 5hall nof em lo an enon in an manne� ���� � ^� ��STRIQ GROUP iY7E FIRE PR ESSED BY '�
P P y y P Y ADDRE55 s( CONST.'/ ZONE V _
so as to beeoma svbjed to the Workers'Compensation laws. .� � . •�
Gt/ -�aG�/ � � � o
Dale ' Applicant - � . CITY . ZIP STATISTICAI CLAS IFICATION APT. NDO.. 1—
ARCHRECi OR� �-}..TEL,�p/ .- � '/ ' . V
•NOTICE TO APPLICANT: If, after making this Cerlificata'6f ENGNFER`.� /2 [71(J N0.6 E' CL455�N0. V � DWEIL.UNITS�� W
�emptlon, you should become�subjecf��fo�the YVorkers' � et
�mpensation provisions af the Labor Code,yau mvst Iorth- AD�RE55��D � SEWER MAP . N
-�ith comply with such provisions or this permif shall be .�
deemed revoked. � . TE�' � g � ,�� YALIOATION
- COMRACTOR NO.
UCENSED CONTRACTORS D£CtARATION - ii�, /�/y �
I hereby aHirm thet I om licensed under provisions of Chapter 9 ADDRESS n70.�J� !o V'O VAWATION
(commencing with Setlion 70()0)of Dlvlsion 3 of the 8usiness and �i�, p l�����
Pro(etsions Code,and my license is}'�full force and effecl. CITY CW55 �U s / ,
/��1// �I(I �/ SQ.F7. NO.OF NO.OF CHECK '
UcenseNumber �•� 7� 7rJ lic.Class �� SIZE STORIES FAMIUES ONE �
���C.�GI`Dafe DESCRIPTIWIOF WORK . .. N� � . . �
Conhoctar J / ADD � . .
❑I am exempf�nder Sec. 'r
/ �J�/c ALTER � FINAI T r j O�ri� _ ,.�''�
B.BP.C. r this reason
G�FLaG `� aEaaiR DATE !'�C�'��J - •.J �
� USE F • FINAL �• ' ' '�� -
Oata: EXISTING BLDG. - DFJ'Aa ❑ B �
-Slgnature APPLICAM TEL. Y �{ y � •�j J�^6 4 _
O ER-BUIIDER DECIARATI N PRiNT NO. ,STj/. - �J�c�i.C3�. .•.•3 J 11.6��s
I hereby affirm lhaf 1 am axempt from the Comrector's License . ' ,
Law for tha following reason(Secfion 7031.5,Business and AD�RE55 � � � Q
Rofessions Code): vee5eN7 � � � I Q�H—"2.
_ _ . ..__. . . ._' _ ._ _ .__ . .- 9111LDING - _... . . . . . .. . .. ._ . _._____.. -'______ -
�- f, as owner of the properry, or my employeas with- ADDRESS - -- � - � � S j 9����� , �
• ` wages as their sole compensation,will do the work and � � -
J fhe structure is not fMended or affered for mle(Sec�ion ��'��TY
7044,Business and Professions CodaJ. MOVING TEt. - �• • • • '�
� 1,as owner of the property,am exclusively contmcting NTRACfOR NO. � � .5��G� .."
with Ifcensed coniracton fo constru[f tha project(Sec- ADDRE55 � - � - �
Iion 7044,Buslness and Professions Code). . , � � " � �
REOUBED TOTAI SETBACK FROM EXISL . •5�T;1.�:n-` .
CONSTRUCTION IENDING AGENCY SEi BnCK YAkD HWY pROP.LINE WI�TH �
I hareby aifirm that the�e is a mn:tructlon lending agency for FRONr � - � �� � (},Q�—Q?
� tha performance of the work for which fhis permit is issued �P.L. , � � - � ,-
(Sec.3097.Civ.C.). SIDE , _ � � �
P.L.
Lander's Nama / � � �
Landei s Address P.C.Fee E 3� y� PamN Fee �/O .�� , �
I ceriify that I have read this opplication and state that the - luuonce Fee �� +S � �
obove information ia mrrecL 1 agrea lo comply with all CounN invesrigor�on Fea ��{-�r�h
rdirmnces and State laws relating to building consKuction, Tarel F�e `�l`--3 �� ' �
ond �eby ao�horize representatives of rhis Covnty o eMer , �
n bo e-memloned property for nspecy � s. - � - � � �
` SiE REVERSE FOR EXPLANATORY LANGUAGE
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