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HomeMy WebLinkAbout1248A (9) WORKERS'COMPENSATION DECLARATION . � I hereby offirm�hot I have a�e«,,;�o,e of Cpnsent to Se�F APPLICATION FOR BUILDING PERMIT insure,or a cerlificare of Workers'Compenstion Insurance,or a certified topy ihe�eof($et.3800,lab.C.) - �OUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyN ��� Company ��6�r�- �U/�t17. 'l � Certified copy is hare6y fumished. FOR APPLICANT TO FILL IN ADDRF55 �G' 3�✓ -�=-�/!��-+��f <-c � Certified capy is filed with the ounty boilding inspeo- BUiIDING '2 1 / • l/ tion departmenr. qooRE55 �) � F � � �OCnLlrv ��+_,a�C� � � NEAREST (- �/ � //i` Oate�-/Z-�Applica / CITY Zi7 - CROSSST. �>. /(��LL<-G�-C� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE � SiZE OF�Ot NOw ON tOi � MAP&OOK GAGE �ne�El - (This section need nof be compleled if the permit is for one n 1C � /� USE ZONE MAP � hundred dollars�5100)or less.) TRACT�// 1 eioCK lOT NO. �/� No - .�..�-=� r � � TEL. �" SFECIAL �y I cerliFy Ihal in the porformance of the work for which Ihis OVfNE .$ NO. � Q � /���vv CONDITIONS O ��� ^ �ISTRICT GROUP TVFE FIRE PROCESSED BY permit is issued,I shall not employ any person in any manner — V ADDRESS i 1 - CONST.� ZONE so as to become subject to the Workers'Compensalion lawz. � �� G: crtv 0 V 1 w il- zia '�� � !L a._e_r,c/ O Dale App�icpnl `_ STAiIS11CAl ClASSIFICATION APi. CON�O. V ARCNItECT OR TEI. � �� NOTICE i0 APPIICANi: If, after making this Ceriificaie of EnlGweeR - NO.�- C�A55 NO..�:1_DwEu.UNi15_ � a Exemption, you should become subject �o the Workers' y Compensalion provizions of the tabor Code,you musl farth- ADDRESS SEWER AMP Z wilh comply with such provisions or this permit shall be TE�. (/ deemed rewaked. CONTRaC . (, � _ { No�3�- � BKJ S PG. YALIDATION LICENSED CONTRACTORS DECIARATION iC. I hereby affirm that I am Lcensed under provisions of Chopter 9 AQ�RES � ���(-� _��i� 'v J NO. � ,� ypLUATION (commencing wilh Section 7000)of Division 3 of the Business and ` t,, LIC. 1 Professions Code,ond my license is in full farce and effect. � CRY d�/)vl ry- CLA55 -1 S (p l�f0� Q"� � c � SQ.FT. 2 NO.O NO.OF CNECK Li[BnSe N��Jtnber/���J./�7� Li[.Class� I SIZE � J STORIES / FAMILIES � ONE Con�r$tt�"��.�.�/��_lCl�W1� te _f-/�-�� DESCRiPTION OF WORK . NEW � S � I om e.empi from ihe licensing requirements as I am a � �77��OM ���)�'� b v�, ADD licensed orthi�ect or a registered professional engineer aL�ER � FfNAt y i( � octing in my professionol copocity ($eUion 7051, REPAiR � �AiE � � � � Business and Professions Code). � uSE OF ' � Ex157ING BlD�q- `� .�� DEMOL ❑ -FINAL,A� Lic.or Reg.No. Date '� APPUCnN . TEL. C gY ���"���� - - OWNER-BU1lDER�ECIARATIDN. � IPRM ��-� /' � L. S(Jw-u10. �Z^ !� ��2 Q'a A .._ . ___ . _' _ "__ . . . . .. . ....... . . . ... '_ _" �_._.. � I here6y affirm thm 1 am axempt from Ihe Comractor's License � C-- - � ---- -----"-- --���--�� - ----- - -- � law for the following reason(Settion 703L5, Business and nooaess: �W�`l-F1 l_1_ n Y?_n i S 1 � �6 �V �.� � � � ��� f ProfossionsCode): . _. . . ppE EN aBUnOiNG 1_•_•6 1,5 0 I, as owner of the proparty, or my employee5 with ADDRE55 woges as their sole compensalion,will do the work and r r .6 1.5 0 the slructura is not iNended or of(ered for sole(Section LOCAIITY V � 7044,Business and Professions Code). MOViNG 7[�. ���� 2-8 2 � -� I,as awner of Ihe properhy,am exdusivaly coNrocting �ONTRACTOft NO. with licensed cantroctors to consiruct the projecl(See � ADDRE55 tion 70a4,Business and Professions Code). CONSTRUCTION LENDING AGENCY REOUIRED TOTAL SETBACK FROM EXiST. SET BACK YAR� HWY p�pp_LINE WIDTH I hereby offirm tho��hcre is a mnstruction lending agenty for FeONT ' ihe performonce of the work for which this permit is iswed v� ' . (Sec,3097,Civ.C.). SIDE P.L. lender's Nome ',�7 j m . P.C.Fee S Permii Fee J'�3- v V lender's Address v W I cerlify ihai have read this applicotion and s�ote thar the i,,,,�„Ce peP p. S U � Qabove infor tion is correU.I ogree to wmply with all County In�esi�gaoon Fee � ardinonc nd Slote laws relafing to building construclion, ioiol Fee ��- S� � and her y ouihorize representotives of Ihis County to enler aupon a6ove-rt/1entioned//ffyyu/q�,����"%}', inspet ion purposes. � a (Llc.� ({K` l l./���1J�'�V / i / W SEE REVERSF FOR EXPIANATORY LANGUAGE - Signature o�Applicont or Aqent D�e��C� � '�s l� r� N C V S �! ^ .Vi�i. N t' � �."�i X�`�-� �t/� �. �' H M .r i-t�.Q p g p .i�a « 4 N �.,'i��:�,'�•L�v G•••``�•„ � X G � O U w s-1�' V .� ' o. � K v+ 6 "�U O �i O O v'a n�' Cv,•.��.. 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