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HomeMy WebLinkAbout1832A 1833A WORKERS'COMPENSATION DECLARATION "� I hereby affirm ihat I have a certificate of consent to ge�f APPLICATION FOR BUfIDING PERMIT insure.or a certifica�e of Workers'Compansation Insurance, or cartified,co y thereof(Sac�.�,.3�o Lab C.) � �,� `Sj'y�^,l,��J�r+�L,170�;—J C1 �} � /�y7�4'�; COUNTY OF l05 ANGELES BUILDING AND SAFETY ��yNo �.ZJr�ipany !�l'\I f/Ll^:���{, Certified copy is heraby furnishad. � fOR APPLICANT TO FILL IN BUILDING/� ��"�n,�-^"' _�� J 1�! A�DDRE55 J F I�J .a'7I Y%'\ .� (J.. , � Cartified copy is filed with�he couny building inspeo BUIIDING �,7 C'p���._- , - � q -�, � tiOn deparimenl. ADDRE55 . C.,..J ._.��L��`� �, �'r-� .��.-.' IOCAItTY�.� �/� �'�';`�t°� .,_.�/.1 oo�e '--L���- nppu�oor �r�-��`��t.� ��r1��'LG`fl�✓iGa � ' / �— NenRes� CITY�� Y.j/y1.��'1� �'T�i�� ZIP ' I�(,/°� CRO55 5T- CERTIFICATE OF EXEMPTION FROM WORKEI25' � No.OF siocs. nssessOa / ��� _ COMPENSATION INSURANCE SIZE OF LOT NOw oN�07 NwP BOOK C c PAGE PARCEL (This section need not be completed if ihe parmit is for one �USE 20NE h'�nP hundred dollars(E100)or less.) . TRAa e�ocK LOT NO. NO. TE�.�-:, `�,. SPECIAL ).. I certify ihat in the performance of the work for which this OwNER _ ; .�'3(" �~ NQt�'-�'`-�-IY.J A CONDITIONS G. permit is issuad,I shall noi amplpy ony person in any manner ��' � f� �ISTRICT GROUP TYPE FIRE �ROCESSED BY � so as to bacome subject to fhe Workers'Compensation Laws. A�DRE55 �.��.�_.'�1���X-�� ���.f�'�(J���_' � CON�}1'� ZONE � �.� V N e� Date AppliCanl ��TY Z�P STATISTICAI CLASSIFICATION APT. OONDO, pc-� NOTICE TO APPUCANT: If, pfter making this Certifimte of ARCHITEQ OR 7EL. �EzemptiOn, you Should becOme Subject lo th¢ Workers' ENGINF.ER ��F��� NO. CtA55 NO.��WELI.UNIT$ C� Compensation provisions of the Lpbor Code,you must forth- qDDRE55 � SEWER MAP �''! ith comply �th such provisions or this permit shall be 1 1EL e; deemad revaked. COMRACTOR -V t ,f�, �� L. � BK. PG, VALIDATION ..t.. -I.�'a r r'�� NO.��I-.� {In LICENSED CONTRACTOBS DECIARATION � r J LiC. ' I heraby affirm that I am licensad unde�provisions of Chapfer 9 ADDRESS �l� 4�!.��/(j",A,J� NO.���?..��'? VALUATION (mmmencing with Saction 7000J of Division 3 of the Business and �i� / a�i Professions Code,and my license is in full force and effect Ciiv /`' �}�(� ����'`- CLn55 �-~'/ ��-�!� bi��,��v'�% � , -7 -��-.��; � Sq.FT. ' NO.OF NO.OF CHECK License Num6eF'��C''��n!� Lic.Cias/s�! ����'�/ SIZE �� STORIES FAMItIES e ONE �'-��v`'t �C:�F-l� � ,�A�_r�4-., NEW 5 0 /., DESCRIPTION OF WORK Con dtl r �ate � � �I am exempt vnder Sec. � �r�(� ��� �(��.�)�.,�_ft�� /..���[I1i� A�D ALTER � FINA� 6.8P.C.forthisreason t�����C� �=�<�� f / � REPAiR � DATE ,� ��r Date: USE Of � (':i� D�,�l FINA !i" EXISTING&OG. . 7 1-�I- L. � SY Y� $ignature APPIICANTt V ) '`/� ,�L /�� PRINT'k . .I I � �JY NO "'l.�-.�J�i I OWNER-BUILDER DECIARATION ' � � ��_ �7C/ I hereh affirm thot I am exem t 4rom tha Contractor's Litensa 7 / � f - , � `��'�> 7�:�"'� law for ihe following reason(Section 7031.5, Business and � �" + ��� � � '"�-�t�-���� � �=��T , � � ti:� �,�i.C{{ Professions Coda): � BUIIDING �o s c o�3 � . I, os owner of fhe prope�fy, or my employaes with ADORE55 woges as iheir sole tompensation,will do the work and the sirocture is no�inlended o�offerad for sale(Sadion iOCnutv j �� ��4 Q(} 7044,Business and Professions Code). MOviNG TEt. � 1,as owner of tha property,am ezclusively confracling 1RACTOR NO. �� �� �������'.(�,�)� wifh licensed confroctors ta mnsfruct ihe projecf(Sec- App�� �,�:�;C-�,� tion 7044,Business and Professions Gode). RE�UIRE� TOTAL SETBACK FROM EXIST. CONSTRUCiION LENDING AGENCY SET BACK YARD HWY pROP.LIN WIDiM , � � S�:J A I hereby affirm fhoi there is a constroction lending agency for FeONT the performonce of ihe work for which this parmit is issued P.L. y, � ` 4 �. • � �Sec.3097,Civ.C.�. � SIDE P.l. Lender's Nome l� � � ��'.j� $ Lender's Address P.0 Fee b � Parm��Fea (y,, °� � ..�.i,`;� � I cartify ihat I have�ead this opplicmion dnd state fhat�he iss� ca Fae � ��'G�"F���c a6ove informar�on is correct.I qgree to comply with all Coumy tmesr�ga+�on Fee �� ordinances and Siate laws relating to building conshuction, Toral Fee G and hereby amhorize representatives of ihis Coon�y to enter ' � uponifhe a've-mentioned pr arty for inspxtiop�purposss.„ / / C�� /%��(5'i � (,Ii�3'�!�.�� ���'� ��` "�..�C'l� SEE XEYHff@ FOR EX►IANAiORY LAMGUA6E ' Signo�u e:of Applimnf or Agbrlt� pay � �� / _..,,._.. . __ �.� __ � . r..... .... � �.____..,�....... ,�°�..'�,..'�'A''�Ysl� IMSRCi"�'bNP4�5�.�..r-.._........ ......�.....__,,...�._ I I ,. . � ' - . ,`�+ Tc: � . .EtyBwMd , -. Li .I,�_ , �� r... c T�37,5) A}�r�wd --r!• ----- ---'�` , . , - �. � : !t _p ��. • ,� ., _ – , ..-..- --- --- �., , , r� � I . "' . Y'- l.,.,. .'li ' j.'.� . 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