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HomeMy WebLinkAbout1179A 3076A 3488A �-.'`� WbRKERS'COMPENSATION DECtARATION '` - � " � �`,��«oracertifca�eof�Wokersr'Compensation��g�,a�a'� - APPLICATION FQR BUI�DING PERMIT � 'or o w rha e f 3 Lab. Po��Y�s���PC���``C_ f � COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereby furnisbed. FOR APPLICANT TO FILL IN AD RESS ��7/ � Certified copy is filed wilh the coonty b�ildfng Inspao- BUII�iNG � tion.departmenL � AD��55 � S, q/Y� �� S. � I YE LOCqLITY -�. �- � � NEAREST Dare Applicant t�Tv I 0 H� �+ LP CRO55 ST. CERTIFICATE OF EXEMPTION FROM WORKERS' � � No.oF s�oc5. Assessoa COMPENSATION INSURANCE . S12E OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one iRAC7 BLOCK LOT NO. U��E NO ��' I hundred dollars($100)or less.) . - r.� TEL o d SPECIAL _ I certify that in�he performance of the work for which Ihis OwNER On �• Q f��7 NO.0�7�'d77 'TD� CONDITIONS d permit Is issued,1 shall nof emp�oy any person in any manner ^ J q� DIS7RICT GROUP TYPE fIRE PROCESSED BY � so as to 6ecome subjecr fo rhe Workers'COmpensafiOn Laws. ADDRE55 p 3 T� S• A P'�0 rl�• U V C Coyii:�' ZONE U «TY i)a o N I�A2 nP q(?6 5 10 � �''`9 0 Date � � Applicont STATISiICAL ClASS TION APf. CON�O. F- ARCHITECT OR tEL. /�� NOTICE 70 APPLICANT: If, after making this Cartificate of ENGiNEER NO. V �Exempiion, you should become su6iecf to iha Workars` CLA55 NO._�tL_OWELL.UNITS_ � Compensation provisions of Ihe�Labor Code,you must forth- qppRE55 SEWER MAP � with tomply with such provisions or this permit shall be TE� I� _ deemedrevoked. . � � CONTRACTOR O,.! � -� NO G`�77 BK. PG. YALIDATION UCENSED CONTRACTORS DECLARATION LIC. � I here6y affirm�hat I am licensed under provisions of Chapter 9 nooRE55 ��7 Z S. j1�11'1��f S. NO. VpLUATION (commenting with Section 7000)of Division 3 of ihe Business and ^ Q IIC. � Profassions Code,and my license is in full fnrce ond effect. Ciiv L� (Y10hf� f✓ft� CLA55 E � $Q.F �8 NO.OF NO.OF CHECK ► itenSe Number 7��Li[.Class�_ SIZE � STORIES FAMILIES ONE s t�`M� �1 1 7.9 A . 1 t.7-� Coniracto�A d �-��C��-v:.�s��___� / • � DESCRIPTION OF WORK 4./. X�3. � NEW � #• • • •2�J ^ /� ADD I om exempt under Sec. C[/�A Sfid r (!��YY) A��R � FINAI � � • •9���8 DATE B.SP.C.for Ihis reason 1�x,� REPAIR � • � •9 1.3 t3 c=.o USE OF F�Np� Date: EXISTING BLOG. ����� sy 0 7,0 8—8 5 $ignature � APP�ICA TEI. OWNER-BUILDER DECLARATION PRINT NO I hereby affirm That I om exempt from the Contracror's llcense . , _ Law for the following reason(Section 7031.5,Business and AODREss � a�o+�s:�o�s cada�: R �3 0 7.6 Fl ❑ BUIl01NG 1, as owner of ibe property, or my employees wi�h ADDRE55 �� � � �C 3 wages as their sole compensation,will do the work and . the strucrore is nat imended or offered for sale(Section �Ocnutr � 7044,Business and Professions CodeJ. MOVING , TEL . . �-•��1 �9 3 � I,as owner of ihe properly,om exclusively contracfing N1RACiOR NO. . . • • e� ��3 U witb licensed contractors to consiruct fhe projed(Sec- qpDRE55 � lion 7044,Business and Professions Code). CONSTRUCTION LENDING�4GENCY REQUIREO YARD HWY TOTAI$ETBACK FROM ewsr. 0 9,2 4--B 5 SEf BACK PROP.LIN WIOTH , . I hareby affirm thar ihere is a construc�ion lending agenry for . ppONi � � the perfarmance of the work for whichYhis perm0 is issued P.L. . �y���� �Sec.3097,Civ.C.). SIDE ' �- - P.L. Lender's Name � . � -� � �� • � � � �. . P.C.Fee S � Permit fee � • � �(.�� Lender's Address . I certif d reod t ' plication and stote Ihat the issua m Fee c e j ���,%;,�'� � a6o mformotion i mrr .I a rse to comply with.all County Invesrigation Fee � � ' a nances and St te a ating to buii ng consiroction, Towl Fee � �Q� �-'Fi� Y nd heraby auth iz resentatives of t County lo en�er � upon�he a6ov tio d property for spedion purposes. � SEE REYERSE fOR EXPUNATORY�ANGUA6E �// Ignature of Applicanl or Agent � 7' � . / / .// �.. � * _' ,��� �}� _�.._ .�. ,az ' •__.__.•.. ' r�''��..�-� �. .,F �a+v.r s-�+. . ...r._. �� c . . r A i h'I�e�i,._ .'s To: � Red4tau$ . I q - i ; � �� .. Uc i - � ._��c sn rcw on. (Y�.� R'�31.5) 4 �c .' __S .:..5��l'l ''� " • J __-.. .: _.. ' __ _ ._ __ _ . . 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