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HomeMy WebLinkAbout1719A WORKERS'COMPENSATION DEGLARATION � I p�U�pU � /✓I Ucl� G! `'1% G� � 6 � I hereby affirm thot I have o certificote of�o�,e��,o=a�F �� APPLICATION �FOR -BUILDING PERMIT ��� � insure,or a certificaie of Workers'Compensolion Insurance, . ' � � or a cenified copy ihereof(Sec.3800,Lab.C.) '"" i NT �F LOS GELES �� BUILDING AND SAFETY P❑ollcyNo. Company FR�hr�' S SOl C' — • 'i Cartified co is hereb forniihed. BUILDING Pv r FOR APPLICANT TO FILL IN ADDRE55 � - �. � Certified mpy is filed with the counly building inspec- � BUUD�NG 1 ,A �f �/- r1 lion deportment. . ADORE55/C�IQA� /�y` �c �y�� �Q ip�,q�ITY � a p2 NEAREST Date `��'a J Applicanl CITV zlp CROSSST. ' �7 , CERTIFICATE OF ExEMPTION OM WORKER$' � NO.OF BlDGS. n55E5sOR , COMPENSATION INS RANCE 512E OF lOT NOW ON LOT MAP BOOK PAGE VARCEL (This section need not be completed if the permit is(or one - TRA�� lOi NO. l U/SE]ZO � OP D C� � i hundred dollars($100)or less.) `� � TEL. /�� JU. SPECIAI UQ } 1 tertify thot in the periormance of Ihe work for which ihis OWNER re le N DSoa � / CONDI710NS d permit is issued,I shall not employ any person in any manner � . DISiRICT GROUP TYPE FIRE �D 0 So OS 10 beC� �me subjecf to ihe Worker'CampQnsa�s. ADDRf55 � �CONS 10� �� �� � � Date 8 Applicont �� CITY Z�P STATIS71CAl QASSIFICATION APT. CONDO. NOTICE TO APPIICANi: It, af�er aking this Cerlificata of ARCHITECTOR TEL. �/� U ExemptiOn, you should 6ecome 5ubjeCt fo IFIe N/orkers' ENGiNEER NO. � CW5$NO.�:�2.��WEIL.UNIT$_ W C Compensation provisions of Ihe Labor Code,you must farth- qDORE55 SE�NER MAP � with comply wiih such provisions or this permit sholl ba j TE� � deemed revoked. fONtenCrOrt L /N� NO. 3 BK. FG, -VALIDATIOH I IICENSED CONTRACTOR$DECIARATION ii�. I here6y affirm ihal I am licensed under provisions of Chapier 9 aooae55 3a � f� �. NO d - VALUATION (tommencing wilh Section 7000)of Divisio�3 of ihe Business ond � ���' ROn, O� Professions Coda,ond my license is in full force and effect. Citv �( Ke wa�d Cin55 C S $ v ► SQ.FT. NO.OF - NO.OF CHECK� License Number 3 3 y YQ lit.CIa55�^a 9 SIZE STORIES FAMILIES ONE f�n ,J y� DESCRIGTIONOF WORK a, D� NEW s Contractor VM�L���7 Date-q � 8� ❑I am exempt under Sec. �e IAII,�✓ V �� ADD._ � �� l�.n{i ALTER � FINAL� 'y " s . e e � i B.SP.C.for ihis reason � � REPAIR � DATE --77 3 ++` I Dole: u5E OF DEMOI BINAI I e `�,'S ', E%iSTING BIOG. ❑ �/�sJ��/ � APPIICANT TEL. Y ll ir�— Si�nolure PRINT NO. ' ' ` � ''`� CijIVNER-BUILDER DECLARATION ���� � I hereby affirm rhal I am exempt from tha Contmcror's License • , �:`•-:_-r- � Low for the following reason(Section 7031.5,Business and ADDRE55 u ^ �� �.� , Professions Code): ', aBWLDING . �, I, as owner of Ihe property, or my employees with ADPRE55 wages as their sole compensation,will do the work and ip�q��iv ihe structure Is not ininnded or of(ered ior sale(Suction � 7044,Business nnd Professions Code�. MOVING TEL. , , � I,os ownor of the property,am exclusively confracting CONTRACTOR NO. . ' � with licensed contractors to tanstruct ihe project(Sec- aDDkESS lion 7044,Business and Prafessions Code). REQUIRED TOTAL SETBACK FROM E%157.� ' CONSTRUCTION LENDING AGENCY SEi enCc YARD HVJY PROP.IINE wioiH I hereby affirm that there is a construction lending ogency(or � ppONi - � , ihe performanca of the work for which Ihis permit is issued v.l _ �Sec.3097,Civ.C.). i SI�E P.L. Lender's Nome I $ P.C.Fee S Permi�Fee Lender's Address ' / � I tertify that I have read Ihis opplicalion and state�hat the '� iss�on<a Feo ! D� Aobova iniormotion is correct.I ogree to comply with all County � Inves�iga�ion Fee ��� �� g ordinences and Staie laws re�ating to 6uilding convmciian, I � Total Fee � CS and hereby aulhorize repr entatives of this County to enter � opon he a ve- nt roperly for inspaclion purposes. � � � ��-- � � �� , I a � �3' SEEREYERSEFOREXPLANATORYLANGUAGE �� Signawre ol Applimnl or Agent Do�e ' . .. . � . . � mi i ... . _. . .. , �. � �� �N V'� �+ [ [ V-� ^�„C`�'y-` L'E�' 'h``'tS-C �` C �\' O C'`_`� ' ` ' _ '- . ,O(7 �•C�� ��7�M i.h•V C ; C^ t�.•�C`F'� C 4 �`� C��+ ~ C' O . ' U 0 .�.. a � y�.`^.�H M C h C� `C '._a. q„ . 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