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HomeMy WebLinkAbout1629A �. j �'� WORKERS COMPENSATION DECLARATION -� . . . . �*,.' . � .. -,1 .. . .�- .. . .. - . � � ��hereby3affirm that I hcve o tert�fimte of consenr to self ' .�pPLICATION SFOR;BUILDIIVG-�PERMIT � ;; i �i sure,�o a ceFtificote of Workers Compensation Insvrance � _ ' I ��1 S�w t�n f ed CopyiFiereof�Sec.3800.Lob.C.I - �,`.. . ' ' .. f " �.' � ` . ... �. ��� r3iPoLcy,No��f��'-•' �� Company���'T'�� r�"=�� � � � ; . . :�.COUNTY OF lOS ANGELES �, � , ,�•.'BUIIDING�AND SAFETY . .� � � i `ECert�hed copy is hereby furnished. � �:FOR APPLICANT•TO FILL IN I�'I � � AppR u jl� � rr '�+"�( , ?" ��� � ' 1�CC�1 i if.�.�/f1>'fr/; �', � lO',ICerirfied capy,is filed wilh tMe co�nty buJding inspec BURDING /l�/��( �y, /� ,. . � f .� �'.', o, I � r - � .i�' ' i �'ondepa�lmenf.- . . ADDRE55 L M� � 1 f) -S..r '.:�t. .� C � ';� .';p-I . . ' �', : Date � �:,^� �'�•' �APplicanr � � � ciTv'��-. r ' t'�a � � ,.���".Zio I i i'i iocnuTr�.r F� ��� �� � � : � � , � I ; �ERTI�E%EMPTION FROM WORKERS' � - � ' �' - , .NO.�OF BLDGS. . i �'�y NE.4RE57' 1.�� {^ � .I $IZE OF lOT NOW ON lOT ��. ;q � Ir�'�I h I��;i 6,'COMPENSATION WSURANCE - J i � CROSSST.:�',}I'I-�.\� Q�LSv�. � �(Thh secHon need nm be completed if the permit is for one �� . 1� � � n55E5SOa�i.t: . . , � - } �; j hundred dollars(E100)or less.) . TRACf' BLOCK �. lOT NO.. ��.. � �� Mp,P BOdC i F��'� � � PAGE PARCEL O:' �1 'I 1. I i,; . , � .( ,�� TEL ' .:.:a.�..:�Y USE Z NE MA7 �- . U ' p 'I tartify Iho�in the performonca of the work for which ihis �WNER !:' � � NO f'--� l,�i� il�� NO. ' ' � Q � � ' �" I permit is iseued,I shall not employ any person in any manner qDDRE55� �:�/ "� 4 �=J`� � �ECiAI . W ' I � �sa 6s fo beCome subject to tha Workeri.Compensafion Lawa. ' I� ��� � "`t'� � In.C����'CONDITIONS��, � J i j' I�i , cm _ '' yr' ",I' ziv: ;fr il���'I ' ( �- '� � �I�I APPliwnt ARCHITECT OR � .... iEL. � � . . � . .� - �NOTICE TO APPLICANT; If, oiter�moking�ihis Gertificate of - . � ' � DISTRICT iGBOUP 7YPE �` �� FIRE � VROCESSED BY ;.� ; � � ENGINEE2 NO. � - �Exemption, you should becoma subjen to the�Worken' . _ _ , �� '� �' � ��y5-,-r �z�E O i Compensation provisions of the labor Coda,you must forth-� qpDRE55 : � ' ' � . �j�Q� ; ; V�� �f � �1�'.�. � wlih�eomply with such provisions or this permi�shall be / �MI. tleemed reVoketl. . � � � CONTRAROR r'� ,. :'t '.�±i NO J�'� U� � STA'ISTICAL ClASS TION� ' �APi. CONDp. W /�e:7�! � .�i�I� i� UCENSED CONTRACTORS DECIARATION , . i ��G �l t � .W55 NO��I � -�DWELL.UNITS E"' , i �I�iereby affirm that I om licensed under provisions of Chepter 9 , qDDRE55 �U'�`� f.��J,r.�(r/-y No ��/� �.� . ,(mmmencing with Section 7000)of Divisfon 3 af Ihe 8usineu ord � , � �I SEWER MAD- " �� � � .� � , ' I Professions Code,and my license is In full force bnd eHect.' Ciiv ..,i%+sJ�+:" �J' '�i""�•� CL455 -��/ � � �� . �VALIDATION S G I.�T. N O.O F NO.O F GM E C K I��I�BK.�'� �'���PG... ' � uc I n ise N�mber 7i�t0'e f+{� uc.Gass �� ,3 `� srze ��' sroeies � Fasnnies / on� •I ' .I '� � .� /' / - .; � - . . - � VALUATION � � - �� - .. I , ���f , I Conlracfar .�( '�/ (.cc�f�.� �� •:� �"' � OESGRIPTIONOFWORK �a .^. i _ :�-t. NEW � 1 t Iil ..' , Dale .� �S�f�'�.f'Vi �r.-�'.L�'f...� � �' �.o i exempt under5ec. ��'� �'� � . s..:J� ..�; :t w C� � I+� , ATER ❑ ��f� �� '� •. . � � . � ., :.'1 �8.8P.C.for this reason � :1�..�'�. �, !�C . � I s�j! I.�I�I � - - � � � , REPAIR • I � . . . � Date: EX SONG BLDG. � .Fr.�r � .�,� DEMOt Q I�� I e �I I � . . � :'�Signa�ure�. . �-. . . . ... naauCnNt � A�Viet. .IkINAI� �' . � ' � . .'`<, I I� OWNER-BUIIDER DECIARATION . : ,oRiNT 'NO. -j DATE � �i � -. ' � �' � 1 hereby affirm�hat 1 om exempt from the Contmctor's License , i-� . . � � � . � � -� . , � Law�fori�he following�reasan(Secfion 7031.5,Business ond ADDRE55 � � � "� I F�rypl � ���� � . ' . , . . Y . ProfessionsCode): ' . gE N ,,, . _ ,.; . � By , . ' I -" BUILDING � - - � - � I,�as�owner�of the proparfy, or my employees.with .. ' ADDRE55 ' II i I � ; �j wages os Iheir sole compansation,wfll do the work and - � ' � � � � 'i�� � �� � . �� . �- - �! � ihe structure is nm Imanded or offered for aale(Settion � ��`��TM ' � �� ' . I ' , �+1�f?L��� ��. 7044,Business and Professlone Code). � � MOVING TEL. , � � � � '��1'��} � O�i I�os owner of the property,om eaclusively comracting �OMRACTOR �NO. ^� � . , ..p��i�i�+����1'" .. ; �, I with licanaed contracton to constr�ct the pro�ect(Sec- n�DRe55 -' � � � � �i, � � . � �� � ��14�C".r � � � tion 7044,Business and Professtons Code). ' � � � REQUIRED .TOTAL SETBACK . f . '.�h;� 4 ' ��': I ( CONSTRUCTION LENDING AGENCY � � �'SET BACK ' YAR� HVJV�, �pROP.IINE "' � 'WI�TII' I I - - ' ' . �L �'•`���'��a ' . � I hereby affirm that thera ia a eonstruc�ion lending agency for pROM . � . ( ' ' � .. � the'performante of iha work for which ihis permil is Issved . I�I � p.L. � � - �i ,' . � . � . ' �' � . - , . (Sec.3097,Civ.C.). - � ' F�SIDE � - � . - � � . v.t. � � � � ��Lender's Nome � � �+ ( - ; I I . . . .�i -.� , � � ,, .-' �X , .""\ . �IDMA Ref.N. � ' . . .. . - Lender's Address P.C.Fee S Germn Fee � , •�� . . .I cai�ify ihat I have read Ihis opplica�ion cnd stale Iha(lhe ' � iasuancs Fee� L-� ��D�V/C M � ' " �F � . . , dbo'va'Information�is eorrect.I agree to eomply with all Couny ' �� in.eaugar o F e., . � � .. - ' . . , . � � � � � ��'$ � �ordinancez and Sta�e laws reloting to building consfruofion. ����I� To�al Fee�'�.. �� ��` I�DMA Perm:M � � � �,& and heieby authorixe rapresaNaNves ofdhia Counry lo entar ' � ' � . .'�. � u oRJ.he above•memioned properry for Inspection pv�posei .: ..� . , - .��., ' ��' .�...�. . .. " ' . � - � �� , . ������ , � ��� � ����,� {� I����,��•f;,,; ��s'',-,„ �,�.%�� jr���f,`�I' SEEREVERSEFOR�EI(PIANAtORYLANGl1AGE i � � �,� �Ignature of AppLcam or Agen1' �te- �� . - � . � . _ I , . �J r - : ' . r. , . � .. : � . �.; ' . � . , . .