HomeMy WebLinkAbout1719A (10) 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. ❑ �/�sl��/ �
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
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