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HomeMy WebLinkAbout11_01_1988 - 2016 PEACEFUL HILLS RD . WORKERS'COMPENSAiION DECLARATION �- ' � - �� � � .. `� : '-' � � � '� - � ���1ja ��'�� hpi B.,•{ I hereby oflirm\inat I have o certificate ot consent�to 5e�f -�� -�-�� -�� �� APPLICATION � FOR�����V�i�■\�4'� inwre,o.o cernRcme of Workers'Compensallon Insorance, � o�o cerrited copy rhereof�Sec.3800,lab.C.) COUNTY OP LOS ANGELES BUILDING AND SAPETY Po�licyNo. Compony fJ;.n�ceK;c���� r,a/N�� BWLDING Certifed topy�s hereby(omished. FOR APPLICANT TO FILL IN ADDRESS � Certified copy is filed with Ihe county building inspeo- �� - BU�I�iNG- � � - � - � tion depariment . . , . . AODRESS O G I=v� %,«S IPD� Da�e�Appliconr, i�GK�11f(//£��iT,/�4f Cttr C�.� iocnim � i� ERT ICA7E OF EXEMPTION FROM WORKERS' . . NO.OF BLDGS. NEAREST . COMPENSATION INSl1RANCE � S¢E OF LOT� NOw ON i0i CRO55 ST. � � ..y�, � � � (This seUion need not be completed if fhe permif is fo�one - TRAC7-- .7 BIOCK lOT NO. 3 '�ESSOR hundred dollors(EI00)or Iess.J MAP BOOK PAGE PAR�L , �. � � TEl)/ USE ZONE 1Ju1P- } a,vr�u m .✓c iL.�,u Fi No. -9 I certify that in the perlormance of 1he work for which this - � MO- � a O: - permit is iss�ed,I shoil not employ ony person in any manner ADDRESS �O � ��L6 � ��� �CiAt O so as fo become subject Io the Workers'Compensetion laws. - CONOITIONS - �-S�� U . . . , .. CITY 1 U� � i ZIP , . � �' DCIe Applicant ... O ARCHITECT OR TEI. NOTICE TO APPLICANT: If, o(ler making this Certificafe of ENGiNEER NO. DISTRICT GROUP TYPE fIRE BY V EYamption, you should become subject ro the Workers' . . . . . . ��T�— �Z� W Compensotion provisions of the labor Code,you musl forlh- � pDDaE55 � � �� �— a wi�h comply with such provisions or fhis permit shall 6e � deeme[Ifevoke[I. � �� - ' �r - -�� STATISTICALCLASSIFCATION AP7. CONDO. Z � �P ✓n,o. — UCENSED CONTRACTORS DEQARATION � � ���, �QA55 NO.� DWEtL.UNITS .. I hereby affi.m tho�I am licensed under provisions of Chop�er 9 ' ADDRE55 G� . G No. 33 � �commenting with Section 7000)of Div�sion 3 of�he Business and f LIC. ��R�P �Q � � Professions Code,and my license is in full force and effect. � � CtTY /�/�-G/�-�- � -�� Qn55 .eK .� ._.. VALIDA ON_ � � 50.fT. NO.OF �f Flp,pf CNECK � � License Nomber�33�syi Lit.Closs� - SIZE STORIES O'�� FAMILIES - � -ONE - � - � // VAIV TION . � ��'';� Co�r.ocra.�2GKHE'yf='Q�w/��iate / d DESCRIPIION OF WORK .�' .L ^'E'PJ. ❑ s � �'OG ,"c�� � , ADD a � � " `%1� C' ❑�am exempt under Set. �R/" /!-G - � __ �,p;�x � c� ALiER ' ' � �-- . = > � B.BP.C.for this reason - . . � . r i�✓ REPAiR ❑ _ � �. J i.;���- . . Oafe: . .. USE OF . � � .. ;��^� � / /� E%ISTING BtOG. DEMOL . Si�naiurn � lYuhL ����j�S<s^^N� � . APPLICANT � .- .. .TEL.J/ . fINA� \-/� � . O NER-V� BUILDERDECLARATION�— PR�M �` �' �`' � OATE S � b\ I hareby a(firM thot I am exempt from the CoNractw i License - ^ i � - - - - ADDRESS�Z�6<II��G�•FL �� U � g C1�I I�LL A Law for Ihe following reoson(Secfion 7031.5,Business and � FIHA�� ��? � _ .Professions Code):-:-----_..-.-._:. .__. . .......... . .. . RE _ ._ _ . . . 9Y S..P�'� _ _..--- - - - - -----�����,�•�� �-- - .... _ ._ BUILDING��G L� � i� � 1, as owner of the properry, or my emptoyees with ADDRE55 � �I��'�4 9.2 5 � . wages os�heir sole tompensation,will do�he work and the structure is not intended or oifered for sale(Section ��`��TY � � � - •�• •4 9.2 5 c=.o .. 7044,Butiness and Professions Coda). � MOViNG TEL � � CONiRACTOR NO. � � . •I��L'�'�I-H S . I,as owner of the properfy,am exdusively confrocting 1 with licensed contmctors to canstruct the project(Sao- _ � ADDRE55 � - - - �� � ��� ��-� - : ' � � �- \ lion 70d4,Business and Professionz Code). . - , .CONSTRUCTION IEN�ING AGENCY _ . . ��gq�K.. YARD_ NWY T�TA'p�p�ME WIDTH -� � � - - � � � � - ' i hereby af(irm that thera is a mnsiroction lending ogenty for FrtONi the performance of ihe work for which Ihis pe�mit is issved P.�. _',i. . . � _ (Sec.3097,Civ.C.�. � � � SIDE . � P.L �' � � . . . Lender's Name � ' �- �" "- � - �7�` LDMA Ref.M � � Lender's Address�- � -�-� -- �--- --- - - P.C.Fee S �� Permi�Fe r/J � , 1 cerfity thaf I have read�his opplication ond sto�a that the . Issuan<e Fee � �DI�M P/C� ' � . � above informa�lon is corretl.1 agree b comply with all County in�es+�ga��on Fee � � ardinances and Stote laws reloting�o building consfruc�ion, Total Fee LDMA aerm.X ' and here y autho�ize representotives of this County to eMer - - - - � opon b bove•menYon r pe�ty for inspection purposes. � . . � _ . .. .. . .. _.. ._. ...__ _ , __. _. . �. -. , �I �� SEE REYERSE FOR E%PIANATORY UNGUAGE � �. 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